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THE 



Diseases of the Mouth 



IX CHILDREN" 

(XOX-SURGICAL). 



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F. FORCHHEIMER, M.D., 

p 

PROFESSOR OF PHYSIOLOGY AND CLINICAL DISEASES OF CHILDREN, MEDICAL COLLEGE OF OHIO; 

MEMBER OF ASSOCIATION OF AMERICAN PHYSICIANS AND AMERICAN 

PEDIATRIC SOCIETY, ETC. 




PHIL A D K I. P II I A : 

J. B. LIPPINCOTT COMPANY. 
1892. 






Copyright, 1S91, by J. B. Lippincott Company. 



Printed by J. B. Lippincott Company, Pmiladel 



PREFACE. 



The contents of this little book were first published in the 
form of a series of articles in the Archives of Pediatrics. 
Since then much has been done on the subject, and in most of 
the articles it has been found necessary to make additions and 
revisions. 

The principal object of the work has been to bring together 
the facts in connection with diseases of the mouth in children, 
which has never been done before in the English language. 
For years the author has been preparing himself for this work 
by collecting clinical material, and his work will not have been 
in vain if he succeeds in helping to clear up the confusion that 
exists in English pediatric literature. 

The importance of the subject dealt with will be recognized 
on all hands ; but the fact that the American Pediatric Associa- 
tion appointed a committee to make suggestions for an accept- 
able and universal nomenclature of the diseases of the mouth 
only emphasizes this statement. One of the principal motives 
for the republication of the articles was to give the medical 
student a systematic course which would give to him a working 
basis for his usefulness as a practitioner. 

F. FoRCHHEIMERj M.D. 
; \nati, October 7. 1891. 



CONTENTS. 



Introduction, 9-18. History, 9. Histology and Physiology, 10-12. 
General Etiology, 12-13. Examination of the Mouth in Children, 
13. General Treatment, 14-16. Classification, 17-18. 

CHAPTER I. 

Stomatitis Catarrhalis, 19-32. Etiology, 19-22. Pathological Anatomy 
and Symptomatology, 22-28. Prognosis, 28-29. Treatment, 29-32. 

CHAPTER II. 

Stomatitis Aphthosa, 33-43. Historical Development of the Subject, 
33-34. Definition, 34-36. Etiology, 36-39. Symptomatology, 39- 
41. Prognosis, 41-42. Treatment, 42-43. Bednar's Aphthae, 43-45. 

CHAPTER III. 

Stomatitis Mycosa, 46-67. History, General, 46-47 ; of tho Fungus, 47- 
Etiology and Pathology, 53-57. Pathological Anatomy, 58-59. 
Symptomatology, 59-64. Prognosis, 64. Treatment, 65-67. 

CHAPTER IV. 

Stomatitis Ulcerosa, 68-86. History, 68-69. Etiology, 69-76. Patho- 
logicnl Anatomy, 76-77. Symptomatology, 77-83. Prognosis, 83. 
Treatment, 83-86. 

CHAPTER V. 

Stomatitis Gangrenosa, 87 -98. History, 87. Frequency of the Disease, 
*7. Etiology, 88-91. Pathological Anatomy, 91. Symptomatology, 
General, 91 92; Local, 92-95. Prognosis, 95. Treatment, Prophy- 
lactic, 95 i General, 96 \ Loral, 96-98. 

(II A PTER VI. 
Stomatitis Crouposa— Stomatitis Diphtheritica, 99-104. Stomatitis 
Orouposa,99 100. Stomatitis Diphtheritica, 100. Symptomatology, 
102 108. Prognosis, 103. Treatment, 104. 



yi CONTEXTS. 

CHATTER VII. 

Stomatitis Syphilitica, 10-3-122. Syphilitic Manifestations in the Mouth ; 
Fissures, 10G-107 ; Tapules, Plaques, 107 ; upon the Tongue, 107-109 ; 
Geographic Tongue, its Non-Syphilitic Nature, 109-114. Syphilitic 
Teeth, 114-117. Hutchinson's Teeth, 117-118. Fournier, 118. 
Treatment, 120-122. Stomatitis Leptothricia, 122-123. 

CHAPTER VIII. 

Dentition, 124-167. The Older Writers, 126-129. The Authors of the 
Nineteenth Century, 129-130. The Development of Teeth, 130-132. 
The Time and Order of the Appearance of Teeth, 133-136. Retar- 
dation of Teething, 136-137. Premature Teeth, 138-141. Late 
Teeth, 142-144. Permanent Teeth, 144. Symptomatology of Den- 
titio Difficilis, Local Symptoms, 144-147 ; General Symptoms, 147- 
154. Treatment, 154. Gum Lancing, 156-167. Conclusions, 167. 

CHAPTER IX. 

The Tongue and the Mouth in Disease of Remote Parts, 168-178. 
Changes in Shape and Size of the Tongue, 170. Changes in Color, 
170-172. Coating of the Tongue, 172-175. Ulcers, 175. The 
Tongue and Mouth in the Acute Exanthemata, 176-178 ; in Disease 
of the Nervous System, 178. 

CHAPTER X. 

Parotitis, 179-180. 

CHAPTER XL 

Epidemic Parotitis, 180-189. Etiology, 180-181. Symptomatology and 
Pathological Anatomy, 182-189. Complications and Treatment, 190- 
191. 



DISEASES OF THE MOUTH 

(XON-STJRGICAL). 



It is difficult to find a subject in diseases of children upon 
which so much confusion exists as upon the above. There are 
many reasons for this. The historical development of the 
subject has been slow; indeed, very little clearing has been 
done up to within the last fifteen or twenty years; then, a term 
first used by Hippocrates (aphtha?) has caused considerable 
confusion. Finally, these forms of disease have suffered, in 
common with all diseases of children, on account of inatten- 
tion, consequently lack of observation, or observation made in 
the direction of some preconceived view or theory only. Hip- 
pocrates and Galen and their followers first used the term 
aphthae, and, by degrees, every trouble that took place in the 
mouth was called aphthous. The distinctions and subdivis- 
ions made were in some instances simply ludicrous. It was 
riot until the time of Bretonneau that diphtheritic sore mouth 
was separated from aphtha?, and some authors drew their lines 
of subdivision so finely that they could make a great number 
of varieties of aphtha; (16 Sagar). The result of this was 
that everything was so completely confused that one writer 
failed to understand the other. Even if our present text- 
books are carefully examined into, notably those on practice, 
it will be seen how lamentably weak, in nearly all instances, 
the chapter or chapters on the diseases of the mouth are, the 
omissions not to be taken into consideration at all. A great 



10 DISEASES OF THE MOUTH (NON-SURGICAL). 

deal of this must be due to the fact that misunderstandings 
arc caused by the very inaccurate and confusing nomenclature 
still in use. In considering the non-surgical diseases of the 
mouth we can divide up the subject into two broad subdivis- 
ions to begin with : first, the diseases affecting those parts 
within the mouth; secondly, those diseases affecting the 
organs outside the mouth whose physiological functions are 
carried on in the mouth. Under the first heading come all 
the affections of the mucous membrane, its various layers and 
its glands, the teeth and the tongue; under the second, those 
of the salivary glands and their ducts. Before going on to 
the separate subdivisions and their discussion, it is necessary 
to take a glance at the physiological processes going on within 
the mouth of a child. From a physiological stand-point, the 
mouth of a newly-born child must be looked upon as a pas- 
sage-way for food endowed with organs of suction. Although 
ptyalin has been found in infusions from the salivary glands 
of the newly born (Zweifel, Ivorownin), the fact remains 
that, for digestive purposes, the mouth can be practically 
excluded. The reason is to be found in the often-repeated 
observation that before dentition the mouth of the child con- 
tains very little saliva. If Ave inspect the mouth of a very 
young child — up to three or four months, seldom later — we 
will find the mucous membrane comparatively dry, the tongue 
always more or less coated and dry, and of a peculiar color 
and reaction to reflected light. The coating is sometimes 
found evenly distributed over the surface, but more commonly 
it is especially developed where muscular activity would have 
the least effect upon disturbing the epithelial layer ; the edges, 
tip, and centre would therefore have a smaller deposit thau the 
other parts of the tongue. If the scrapings of such a tongue 
be examined under the microscope, it will be seen to be made 
up principally of food-remnants and epithelial cells, the for- 
mer predominating. In the healthy adult the saliva is poured 



DISEASES OF THE MOUTH (xOX-SUEGICAL). 11 

out upon the least excitation, central or reflex, therefore the 
tongue is usually clean, as the mouth is constantly washed by- 
fluid ; but in infants this rarely takes place, even after the 
administration of sialagogues (jaborandi perhaps excepted), 
therefore the tongue is coated and the mouth dry. When we 
take into consideration how much value is still attached to the 
appearance of the tongue in disease, this fact is worthy of con- 
sideration. Usually the salivary glands begin to be called 
into activity before the teeth make their appearance, — the time 
varies very much, sometimes as much as three or four months 
elapsing. It is impossible to say whether this is due simply 
to reflex activity or progress in development of the glands. 
It is certain that if the mouth of a newly-born infant is 
irritated mechanically, very little if any saliva will flow. 
Again, if we irritate the mouth of an infant beginning to 
produce saliva, the increase will be hardly appreciable. If 
there is, then, a reflex mechanism at work in these instances, 
it must be an incomplete one, either as to the sensitive nerve, 
the centre, or the secretory nerves. The secretory nerves do 
not seem at fault, for, first, there is a quantity of saliva 
secreted, and, secondly, if the diastatic power of this saliva be 
tested in the usual manner, it will be found to be good; per- 
haps not always as rapid as with adult saliva, but sufficiently 
BO i') show that ptyalin is present in adequate quantity. As 
far as concerns the action of the salivary centre, at the origin 
of the seventh and ninth cranial nerves in the medulla, we do 
not possess any facts which could lead us to suppose that it 
acts differently in infants than in the adult; yet this might be 
possible, as the brain of an infant does perform different and 
incomplete functions from that of an adult. The experience 
of Mischterlioh — no irritation, no saliva — does not help us out, 
for, if any irritant be put into the mouth of an infant, reaction 
in the form of motion will tak<- place and yet no saliva may 
follow. Experiments and observations in this direction would 



12 DISEASES OF THE MOUTH (NON-SURGICAL). 

be very desirable, not only on account of clearing up those pro- 
cesses, but also because of the important role the nerve-mech- 
anism of the mouth has always played in infant etiology. 
When the flow of saliva has been started, the mouth of the 
infant does not change its character to an adult mouth imme- 
diately, for the simple reason that most of the saliva flows from 
the mouth, and not through it. The tongue, especially, re- 
mains as it was, as the saliva from the parotids flows along the 
cheeks, between them and the partly-opened mouth, and that 
from the submaxillary and sublingual glands over the lips. 
Very little saliva is swallowed, so that its digestive activity, 
and with it that of the pancreas, must still be very limited, — 
a fact of great importance in dietetics. The nature of the 
food — coagulability, adhesibility, fluidity — must also be taken 
into consideration in estimating the appearance of a child's 
mouth, so that peculiarities are common long after the salivary 
function has been thoroughly established. The appearance of 
the teeth marks an epoch in the development of the child, and, 
as has been the case with all physiological processes, most, if 
not all, of the ailments of childhood have been ascribed to it. 
The question of teeth and teething is of such value to us as 
physicians that it will be discussed separately. 

On the subject of etiology our lack of knowledge is still 
great, although much has been done within late years. No- 
where in the human organism do we find so admirable a field 
for the development of lower forms of life as in the mouth of an 
infant. The great number of forms present (Miller describes 
twenty-five varieties) has undoubtedly made the work of bac- 
teriologists doubly hard, and in some instances must have 
made it futile; but, with advanced methods and repeated, 
patient efforts, very much more will be accomplished. As far 
as general symptomatology is concerned there is but one symp- 
tom that need be specially dwelt upon, and that is pain. This 
is present in nearly every form of sore mouth, and in some it 



DISEASES OF THE MOUTH (nOX-SURGICAL). 13 

is the prominent symptom. It is a good rule to follow, that 
when an infant is suffering with pain which cannot be local- 
ized, to examine its clothing, its mouth and throat, and its ears. 
Those possessing clinical experience have seen children who 
have been crying for days, who have perhaps been treated by 
physicians, taken opiates or chloral, in whom an examination 
reveals stomatitis ulcerosa. The diagnosis made, the whole 
picture will clear up in twenty-four hours upon proper treat- 
ment. A case of this description is the more remarkable be- 
cause the mouth of a child can be so readily examined. It is 
not necessary to carry a set of instruments for the purpose ; 
all that is required is good light and, if necessary, a separation 
of the lips or the holding dowu of the tongue with a spoon. 
A tongue-depressor ought not to be used, for several reasons : 
a little child will always be more frightened at an instrument 
with which it is not familiar than at a spoon, and, secondly, a 
tongue-depressor may be the means of carrying infection if not 
kept aseptic. The latter, although theoretically the case, in 
busy practice is apt to be neglected, and damage is very easily 
done to an already inflamed mouth. On account of the facility 
witli which the mouth is examined, the purely clinical aspect 
of our subject is perhaps best understood, but for the same 
reason most often neglected, as we are apt to overlook those 
things that are nearest. It is necessary to call attention to the 
fact that in the treatment of all diseases of the mouth cleanli- 
of the highest importance, although the experiments of 
Fischer seem to show that even this may do harm. It is 
astonishing to see how the idea of cleanliness varies, both with 
the laity and physicians. With the latter it will only be a 
matter of time until perfect cleanliness is thoroughly under- 
stood and appreciated. It is not beneath the dignity of a 
physician to teach his patients how to cleanse. Roughness, 
too, s Ik add be avoided in treating sore mouths; not to mention 
the pain that is given, we do absolute harm by using median i- 



14 DISEASES OF THE MOUTH (XOX-SUEGICAL). 

cal violence. In but one form of stomatitis is it necessary to 
remove anything; in all the rest, applications made by the 
gentlest means will give the best results. As was first shown 
by Rajewsky io diphtheria, all inflamed mucous membranes 
arc more susceptible to infection than healthy ones. If we are 
dealing with infectious processes, and this is the case with 
many of the affections of the mouth, it will be seen how injury 
to the mucous membrane can only lead to an extension of the 
process. Hunt and West were the first to use chlorate of 
potassium in the treatment of diseases of the mouth, and since 
that time the remedy has been used by the profession, and in 
some cases has been regarded as a specific. This remedy lias 
deservedly retained its place upon our list of drugs; and it 
acts equally well if applied locally or by the stomach, — a fact 
of great importance, especially in the treatment of younger 
children. It appears in the saliva, when taken internally, 
after a very short time (from five to ten minutes), and its secre- 
tion continues for some time, so that it is best given in small 
doses at short intervals. Its use, however, is not unattended 
by danger, — a fact which Jacobi was the first to call attention 
to, — as it affects the secretion of urine, and may even produce 
anatomical lesions in the kidneys. Jaederholm (1876) was the 
first to call attention to the fact that methaernoglobm was pro- 
duced by the action of potassium chlorate upon blood, and 
Marchand (1879) followed by showing the connection between 
this fact and the symptoms observed in cases of poisoning with 
this drug. He, as well as Jacobi, describes the lesions in 
the kidneys, but he lays most stress upon the change in the 
blood, and Mering, in a very important memoir (" Das Chlor- 
saure Kali," Berlin, 1885), contributes further knowledge in 
that he explains some of the concomitants necessary to make a 
comparatively small dose lethal. He claims that a small quan- 
tity of potassium chlorate is decomposed in the blood ; under 
all circumstances, by far the greatest quantity leaving the sys- 



DISEASES OF THE MOUTH (NON-SURGICAL). 15 

tern unchanged by the kidneys and the salivary glands. The 
result of this decomposition is methaemoglobin, a very small 
quantity of which does no harm in the circulation. This 
methsemoglobin leaves the circulation by being excreted in the 
urine. Poisoning by potassium chlorate may act in two ways; 
first, by destroying the oxygen-carrying function of the blood 
by a wholesale conversion of oxyhsernoglobin to methaemoglo- 
biu ; secondly, by causing a choking up of the kidneys with 
methsemoglobin and detritus from the destroyed red corpuscles. 
In the first instance a large dose has been taken, and death fol- 
lows in a comparatively short time; here the prominent post- 
mortem evidence will be the change in the physical appearance 
of the blood. In the second instance large or comparatively 
large doses have been taken for some time, and death follows 
in from two to fourteen days; in these cases both the blood- 
changes and the changes in the viscera, kidneys, and spleen 
will be observed, and Mering calls attention to the fact that 
in all those conditions in which there exists in the blood an 
increase of the acid phosphates or carbonic dioxide, or in 
which the alkalinity of the blood is only slightly diminished, 
the toxic effects of potassium chlorate are enormously increased. 
Marchand was the first to insist that use of potassium chlorate 
ought to be abandoned in children, and we see this statement 
repeated by Landerer, who recommends that its internal ad- 
ministration be given up entirely, especially in children 
(7 )> mtechea Archivfur Klhmche 3Iedicin, xlvii., 1890, p. 125). 
The answer may be given that, as soon as a substitute is 
found for the potassium chlorate, this will certainly occur, 
especially in very young children. At the present, however, 
it seems to the author that more harm would be done by not 
prescribing this drug than by administering it judiciously. 
In doses to be recommended, and with the precautions men- 
tioned before, its use is as safe as that of any of the drugs 
possessing toxic effects. The fact must not be lost sight of, 



16 DISEASES OF THE MOUTH (xOX-SURGICAL). 

however, that potassium chlorate may act as a violent poison. 
In order to prevent this, two things are necessary : not to give 
too large doses of the drug, and, secondly, to impress upon 
the attendants the necessity of watching the child in certain 
directions. It has been the result of the author's observation 
that the symptoms of chlorate of potassium poisouing do not 
develop suddenly, but are usually preceded by symptoms which 
will give plenty of time to prevent dangerous consequences 
if the remedy be stopped. These symptoms are diminution 
or cessation of formation of urine, and great drowsiness, — 
they usually go together, and are to be looked upon as a 
warning. In some children, especially infants, chlorate of 
potassium will act like a large dose of opium. 

It is proper, in this connection, to call attention to the fact 
that diseases of the mouth, especially in infants, and more so 
in some forms than in others, are not to be treated as purely 
local affections. If we abstract entirely from the recognized 
fact that some of these diseases have a constitutional origin, 
and that many more are provoked by general predisposing 
causes, there is still left a factor which must make us very 
cautious in observing the general effects of these maladies. 
Especial reference is made to the connection that exists be- 
tween the mouth and the rest of the alimentary canal. It 
seems that under normal conditions the gastric juice is in a 
condition to destroy most of the lower pathogenic forms of 
life, but if we consider how finely balanced is the digestive 
process in children, and how little it takes to convert eupepsia 
into dyspepsia, it will be seen how disastrous may become the 
swallowing of large quantities of saliva and mucus, if by their 
chemical interference only. Now, add to this lower forms of 
life in the saliva, which, under the changed conditions in the 
stomach, cannot be destroyed, the effects will be still more 
marked. It is not surprising, therefore, that a great many 
authors have sought a causal connection between diseases of the 



DISEASES OF THE MOUTH (NON-SURGICAL). 17 

stomach and diseases of the mouth, — as disturbances of diges- 
tion are so common with disturbances in the mouth, — but that 
the primary cause was referred to the stomach was rather re- 
markable. It is not an infrequent experience to see a case of 
stomatitis ulcerosa treated with strict diet, which cannot do 
harm until pushed to extremes, because " the sore mouth comes 
from the stomach." The author lias seen children, with con- 
ditions of the mouth probably congenital and possibly lasting 
during the lifetime of the patient, put upon rigid diet, made 
to take pepsin, arsenic, or what not by most reputable practi- 
tioners, only because all diseases of the mouth have their origin 
in the stomach. It is unnecessary to add that the results of such 
treatment were nil, and a few local applications were sufficient to 
alleviate those symptoms which brought the patient to the physi- 
cian. As will be seen, the term stomatitis has been retained, to 
mean sore mouth. Strictly speaking, this is incorrect, as stoma- 
titis means an inflammation of the mouth ; but classification 
becomes very much easier by retaining this term, which is used 
by nearly all nations, and therefore it facilitates memory by 
bringing all forms together under one heading. If the mind 
can group things together in this way, differential diagnosis also 
becomes easier, and the attention will always be called to the 
whole group, from which the individual can be more readily 
selected. The great objection to this classification is that in 
order (<> make it complete so many species must be made that 
it becomes bulky and we counteract the benefits before men- 
tioned. This can be prevented, however, by rejecting special 
Dames lor those forms that are symptoms of general diseases, 
and which belong to the latter,as stomatitis scarlatinosa, stoma- 
titis erysipelatosa, etc. The use of a Latin instead of an Eng- 
lish term is certainly advisable, as it gives to all physicians of 
the world a common language, which, in these days of rapid 
interchange of thought, is highly important and time-saving. 

/ 



18 DISEASES OF THE MOUTH (xOX-SUEGICAL). 

In the classification which we will follow we" make the follow- 
ing subdivisions : 

I. Stomatitis catarrhalis. 

II. Stomatitis aphthosa. 

III. Stomatitis ulcerosa. 

IV. Stomatitis mycosa. 
V. Stomatitis gangrenosa. 

VI. Stomatitis crouposa. 

Stomatitis diphtheritica. 
VII. Stomatitis syphilitica. 



STOMATITIS CATARRHALIS. 10 

I. 

STOMATITIS CATARRHALIS. 

This form of trouble has also been called simple stomatitis. 
By some of the English authors it has been described under a 
common heading with follicular and aphthous sore mouth, 
from which it can be, however, most readily distinguished. 
Two subdivisions can be made: first, a local; secondly, a gen- 
eral catarrhal stomatitis. 

Etiology. — Catarrhal stomatitis may be produced in various 
ways. For its production it is necessary to consider two 
things: first, an irritant; secondly, the mucous membrane. 
The irritation may consist of very many agents; it may be 
mechanical, thermal, chemical, or some lower form of life 
which acts either mechanicallv or chemically. The teeth 
have been looked upon as the most common mechanical agent 
in producing stomatitis. While there can be no doubt about 
the fact that when a tooth is about to appear there is more or 
less injection and swelling of the gums, yet in a healthy child 
this alone would never be sufficient to produce a general stoma- 
titis. There are various well-marked lesions which are pro- 
duced by teething, and which will be considered at some future 
time, but for the production of a general catarrhal stomatitis 
the second etiological factor mentioned above must be present. 
Lack of cleanliness in the mouth is a well -recognized cause 
for the trouble under consideration. This may be causative in 
various directions, quality and quantity of food being the most 
important, and their action being chemical and mechanical. 
A child fed upon food which is in fermentation, which has a 
very acid reaction, or particles of which are apt to remain 
in the mouth, will suffer more or less, depending upon the 
intensity of the irritation. The same can be said for food 
introduced at too high a temperature. Many mothers are in 



20 DISEASES OF THE .MOUTH (NON-SURGICAL). 

the habit of feeding their children with milk which is too 
warm, and in tea-drinking countries, like England, it is not 
uncommon to find even more serious affections follow the in- 
troduction of this beverage when too hot (retro-pharyngeal 
abscess, Bokai). An increase in quantity of food will produce 
stomatitis in an indirect way by causing trouble with the whole 
alimentary tract. Any weak chemical irritant acting foralong 
time, or a comparatively strong one when swallowed rapidly 
and mixed with much saliva, is apt to produce this affection. It 
is difficult to conceive of eructations of sour-stomach contents, 
when not habitual, causing a sore mouth, yet vomiting, when 
extending over a long time, is apt to be followed by it; al- 
though here, again, it is difficult to say whether the cause 
which has produced the dyspepsia has not also produced the 
sore mouth. As far as lower forms of life are concerned, it 
is impossible at the present time to say positively that any 
of them can be looked upon as causative. To my knowledge, 
no experiments have as yet been made in this connection. 
There is one fact, however, known long before the days of the 
culture-tube, and which points in this direction. lit has been 
thoroughly understood for the last ten years, at least, that 
nearly all forms of sore mouth are preceded by a stomatitis 
catarrhalis. For this an explanation can be found in two ways 
only: either the same cause is at work for stomatitis catar- 
rhalis and the other forms, or it is necessary that the mucous 
membrane be in a proper condition to be affected by the poisons 
of the other forms only after it has been first made catarrhal. 
The latter is the view held by very many authorities, it being 
most commonly expressed by the statement that the child is 
suffering from malnutrition, a dyscrasia, scrofula, or what not. 
One quotation will suffice: " Follicular (or simple) stomatitis 
is not a serious complaint, though it indicates a weak state of 
health and a faulty nutrition" (W. Fairlie Clarke in Quain's 
"Dictionary"). While it is difficult to disprove such a statement 



STOMATITIS CATARRHALIS. 21 

as the latter, it will be seen, upon closer investigation, that tlie 
stomatitis and the intestinal catarrh or dyspepsia accompany- 
ing it is the cause of the "weak state of health," and not the 
result. However, that " a faulty nutrition," or whatever it may 
be called, has a decided effect upon producing stomatitis will 
be pointed out later. Whether or no o'idium albicans, the 
various pathogenic sehizomycetes, also produce the combina- 
tion of symptoms which we call stomatitis, as well as dyspep- 
sia, is a thing to be decided by direct experimentation, although 
there are a great many facts in bacteriology which would lead 
us to suppose that this might be possible. If we accept one 
view or the other, the subject of catarrhal stomatitis assumes 
great importance when we recognize that this disease may lead 
to others of a much more serious nature, which may be pre- 
vented by proper treatment. As far as the second etiological 
factor, the mucous membrane itself, is concerned, it must be 
remembered that it is in direct continuous connection with the 
mucous membrane of the nose and the pharynx. A catarrh 
of any one of these membranes may extend itself to the mouth ; 
this does occur, but not frequently. Finally, a non-healthy 
mucous membrane, whose nutrition is impaired by disturb- 
ance in circulation either in the blood- or lymph-vessels, or 
whose blood-supply is otherwise not good, would naturally 
form a better soil for the implantation of pathogenic causes 
than a healthy membrane. From such a mucous membrane 
it would also be more difficult to remove such causative agents, 
as it would require less time for them to gain a foothold. A 
so-called scrofulous child would be more apt to suffer with sore 
mouth than a healthy one (lor mechanism set; Buck's "Hand- 
Book," article " Tuberculosis of Glands"). The same would 
be true for a child whose resistance-power is reduced by any 
of the febrile diseases which last for a considerable length of 
time — typhoid fever, malaria, the acute exanthemata — or by 
chronic intestinal diseases. It will he seen, then, that the con- 



22 DISEASES OF THE MOUTH (NOX-SURGIOAL). 

clition of the mucous membrane is of the highest importance 
in the prevention of stomatitis; and, undoubtedly, with a little 
care a great many diseases — diphtheria, for instance — could be 
prevented if apparently trifling abnormalities would be looked 
after more closely. Bad cases of harelip or cleft-palate will 
cause more or less chronic stomatitis, as the air is constantly 
brought into contact with the mucous membrane, which ought 
otherwise to be closed off, at least temporarily. In the local- 
ized form the causes are, in general, the same as those for the 
other form, only not so extensive in their action. Most com- 
monly we will find some quite localized irritation, — a sharp 
tooth or pus flowing from a chronic perialveolar abscess, — 
which keeps up a condition of inflammation. Again, it may 
be some article of food or a method of feeding. In some parts 
of Germany that ingenious device called a Lutsch-beutel always 
succeeds in getting up a stomatitis, either local or general. 
With us some of the beautiful apparatuses invented to facili- 
tate teething, especially when they are rolled about the floor 
or contain materials which can be fermented or are otherwise 
unclean, succeed admirably in accomplishing our end. At all 
events, the cause can be readily removed in most instances, 
and, unless harm has been done in other directions, the patient 
rapidly recovers. 

Pathological anatomy and symptomatology will be con- 
sidered together, as all observations can be made during life. 
Catarrhal stomatitis has no favorite starting-place, nor can we 
say that it limits itself to any especial locality in the mouth, 
except in the rarer localized form, in which the appearances of 
the mouth do not differ from those of the generalized form, if 
we take extensity of affection into consideration. The tongue, 
the soft and hard palate, the cheeks, the buccal surface of the 
lips, and the mucous membrane covering the jaws are all 
affected. If we look into the mouth of a child with simple 
stomatitis we see various grades of change: first, the erythe- 



STOMATITIS CATAERHALIS. 23 

matous ; second, the true catarrhal. Further subdivision is un- 
necessary, as in all other forms, especially in the one by many 
authors called follicular, all the changes are the logical out- 
come of an inflammatory process upon a peculiarly constructed 
mucous membrane ; just as acne vulgaris is found upon the 
skin. In the erythematous form the whole mucous membrane 
of the mouth takes upon itself a more or less deep red. color. 
The process can be looked upon as the result of irritation 
which is not sufficiently intense to be followed by inflamma- 
tory reaction. There exists, then, hypersemia only, which, as a 
rule, is of such a transitory nature that deeper changes do not 
follow. The hyperemia may be so well marked — and this is 
often the case in newly-born infants — that rhexis occurs, fol- 
lowed by slight hemorrhages, or red corpuscles may be forced 
out into the lymphatic spaces of the subepithelial connective 
tissue, whose coloring- matter changed to haematoidin will give 
a distinct yellow tint to the mucous membrane. This is espe- 
cially the case over the hard and soft palate, a process analo- 
gous to the one in the skin in icterus neonatorum. The con- 
dition of erythema of the mouth may be looked upon as normal 
in the newly born, and requires no attention, as it disappears 
after the first week of life, rarely lasting longer. This process 
being a very superficial one there are no changes in the glands, 
cither of the mucous membrane or of the lymphatics. There- 
fore the functions of the mucous membrane are not interfered 
with. As a rule, there is no hypersecretion, but, on the con- 
trary, there exists more or less dryness of the mouth, which 
must find its explanation in the fact that the temporary nutri- 
tion of the epithelial coating is interfered with. There is one 
form of erythema to which especial attention must be called. 
It is found in pertussis and, as far as the tongue is concerned, 
in measles. 

The appearance of the mouth in the acute exanthemata will 
be discussed in another place, but the following description 



24 DISEASES OF THE MOUTH (XOX-SUKGICA L). 

also holds good for the tongue in measles. If we look at the 
mouth of a patient suffering with pertussis, perhaps the most 
striking thing to be observed is the blue color of the tongue 
and the rest of the oral cavity. The mechanism is simply the 
production of venous hyperemia by the repeated attacks of 
coughing, which prevent the ready return of blood to the right 
side of the heart. In measles this bluish color is due partly 
to the cough, partly to the appearance of an eruption in the 
mouth, and in both conditions it sometimes helps in making a 
diagnosis. It is not, however, characteristic of either condi- 
tion, as, like the ulcer of the frenulum linguae of pertussis, it 
may exist with any cough that is persistent or comes in fre- 
quent attacks, like the cough of enlarged bronchial glands or 
of tracheitis ; or it may exist in troubles of the respiratory or 
circulatory organs which prevent the blood from returning to 
the heart, or in which the blood is insufficiently aerated, as in 
catarrhal pneumonia, pleurisy with large effusion, insufficiency, 
of the valves of the heart, etc. If we add that a slight rise 
of temperature iu an infant will produce erythema of the 
mouth, and that sometimes lesions of the skin of an erythema- 
tous nature are accompanied by the same change in the mouth, 
we have said all that need be said of this trouble which may 
be of importance from a diagnostic stand-point, but hardly in 
any other direction. It is doubtful, indeed, whether a simple 
hyperemia can be accessary to the development of any other 
disease of the mouth. The form described in counection with 
pertussis might be looked at in this direction, but in many 
cases the border-line of erythema and inflammation is over- 
stepped, and then we are dealing with catarrhal stomatitis, 
which is of far greater importance in all directions. In indi- 
vidual cases it may become very difficult to say whether it is 
erythema or something more that we are dealing with, although, 
as a rule, the tissues which are involved will readily clear up 
the question. 



STOMATITIS CATARRHALIS. 2o 

In catarrhal stomatitis the lesions are so well marked that, 
with ordinary care in examination, it is difficult to over- 
look them. In this form of trouble we have, as a rule, all 
the symptoms of inflammation, — swelling, heat, pain, — which 
manifest themselves differently according to location. The 
whole lining of the mouth is red, there is hypersecretion after 
the process is well under way, and the temperature of the mouth 
is increased. If we examine carefully it will be seen that the 
mucous membrane lining the cheeks is puffy; if there are any 
teeth, it is marked by depressions where the swollen membrane 
presses upon them. The color of this part of the mouth, espe- 
cially of the depressions, is paler than the rest of the mucous 
membrane, and it is not uncommon to find these little valleys 
surrounded by elevations whose contours are marked by dilated 
vessels. The slightest injury causes a rupture of these already 
weakened blood-vessels, so that slight hemorrhages or saliva 
mixed with blood are not infrequent. Over the hard palate 
the mucous membrane is not much swollen, for anatomical 
reasons; but the injection of the blood-vessels is well marked, 
sometimes general, at others more or less localized. 

In older children the mucous membrane behind the upper 
incisor teeth is, as a rule, very puffy, although not very red, 
and very painful. In infants this part is also affected, but not 
to the same degree, yet not infrequently it takes upon itself a 
Bpongy appearance, although it does 'not appear faceted as in 
older children. The lips are swollen; if taken between the 
fingers they are more tense than normal, and their inner aspect 
is very much reddened. The surface of the mucous membrane 
is made uneven by small round prominences. These are the 
muciparous follicles whose ducts have become partially stopped 
Up, or in which the secretion has accumulated SO rapidly that 
the whole body of the gland is filled up. Sometimes there 
exists complete occlusion of the duct, then there follows an 

enormous dilatation of the gland, which manifests itself in the 



26 DISEASES OF THE MOUTH (^OX-SURGICAL). 

production of a cyst. When this cyst is opened a small quan- 
tity of mucus is discharged, but the cyst is liable to refill, 
emptying itself by being broken from time to time, and always 
forming again unless active treatment is used. This is a com- 
paratively rare complication, and, as a rule, the ordinary gland- 
ular involvement of simple stomatitis runs its course, even 
without the production of ulcerations. 

On the other hand, slight epithelial abrasions over these 
swollen follicles or in other parts of the mucous membrane are 
by no means rare, even in infants, although they rarely lead to 
the involvement of the deeper layers. The tongue is at first 
covered with a dry whitish coating, quite uniform over the 
whole surface; as secretion increases this becomes more moist, 
and is washed off in places, usually about the. edges. With 
this, the tongue — its upper surface at least — may be slightly 
swollen, and its color soon changes. The coating is no longer 
of a chalk-white, but grayish or even yellowish, and it may 
look as if the epithelial layer might be stripped off in a flake 
without detriment to the organ itself. This does not occur, 
however, as the process seems to affect the older cells only, 
rarely leaving the mucous membrane completely denuded, due 
undoubtedly to the fact that there is so much fluid present in 
the mouth. Through this coating the fungiform papillae, very 
much swollen and injected, are visible. The tips of the fili- 
form papilla? are involved in the general process going on in 
the epithelium, but their bases seem to remain intact even 
where the epithelium falls off, so that the tongue never has 
the appearance of a strawberry or the hilly, shaved syphilitic 
tongue. Where the epithelium is partly stripped off we have 
an intensely red color. The edges of the tongue are rounded 
off, and where there are teeth we find the same depressions 
noticed in the cheeks. 

If with stomatitis catarrhalis there is associated a process 
accompanied by continuous fever (typhoid, remittens or the 



STOMATITIS CATARRHALIS. 27 

exanthemata), we have all that has just been mentioned ; but 
after a few days the epithelium dries up and falls off, leaving 
a raw surface, sometimes fissured, the color of which varies 
greatly, principally on account of the quantity of blood pres- 
ent upon it. The whole mouth partakes to a greater or less 
extent in this change, producing the dry, cracked, lips, the 
sordes upon the teeth, etc. 

In all cases the lymphatic glands supplied by the mouth 
are more or less involved, and it is a safe rule to measure the 
grade of the stomatitis by the amount of enlargement there is 
in the lymphatics. There are mild, forms of stomatitis catar- 
rhalis that affect the patient very little ; sometimes, even, we 
are astonished to find a very extensive inflammation with very 
little general reaction on the part of the patient. As a rule, 
however, the patient complains of well-marked symptoms 
which alone will lead the initiated to localize the seat of trouble 
in the mouth. There is usually present more or less fever, 
rarely going very high, going down to normal in the morning 
and up to 101°-102° F. (rectal) in the evening. In some 
children the temperature may go quite high (104° F.), and 
may require special attention. 

The prominent symptoms of stomatitis are the manifesta- 
tions of pain and the hypersecretion of saliva. The little 
patient, if an infant, goes at the breast with a good will, evi- 
dently hungry, takes one or two pulls, then suddenly lets go 
of the nipple and begins to cry. By means of a little coaxing 
the mother will be able to succeed in getting the little one to 
try again, but the same result follows, and, finally, the baby 
refuses absolutely to be put to the breast, preferring to remain 
hungry to suffering pain. In the intervals between feeding 
tli«' child may be cross and fretful ; it may whine considerably, 
but does not cry out very much, as in some other forms of 
stomatitis. At the same time the child, if old enough, is 
drooling constantly, the saliva flows from its mouth freely, and 



28 DISEASES OF THE MOUTH (xOX-SUEGICAL). 

the mother is apt to be happy over the whole condition because 
she thinks her baby is teething. This increased flow of saliva 
produces irritation of the skin over the lower lip, the chin, 
sometimes the neck, and many an eczema is started up by 
stomatitis. Long after the irritant — the saliva — has been re- 
moved the eczema still remains, and may give rise to eczema 
in other parts of the body or universal eczema. Bohn states 
that the reaction of the saliva may be neutral, never alkaline; 
I have never been able to find any other reaction than an acid 
one. As has been pointed, out in the introductory chapter, not 
every infant or child drools, so that this symptom is frequently 
absent. 

The effect of a simple stomatitis upon the general condition 
of a child or infant may be nil or it may be of the severest 
nature, even costing the child its life. Just as a nasal catarrh 
may prove fatal, so a stomatitis may kill by preventing the 
child from taking its food, — i.e., more or less directly. This 
manifestly is the rarer modus; but given a badly-nourished 
infant which becomes affected with a stomatitis, and two or 
three days of complete abstinence from food will be sufficient to 
reduce the vitality to such an extent that recovery is impossible. 
Or the stomatitis may produce dyspepsia, catarrhal conditions 
of the intestine, and death in this way. It is not uncommon 
to see dyspepsia set up as the result of bronchitis, a coryza, or 
a stomatitis due possibly to the swallowing of something 
coming from one of the affected mucous membranes. This 
"something" may be an increased amount of fluid or fluid 
containing an irritant; in either case followed by reaction, 
which causes dyspepsia. The fatal termination, again, is rare; 
but commonly do we find the child's nutrition suffering, so 
that great care and attention are required to save the child's 
life in attacks of other diseases. 

It will be seen, therefore, that, quoad vitam, even this ap- 
parently trifling affection is of great importance. It may 



STOMATITIS CATARRHALIS. 29 

bo stated, furthermore, that, once a child lias had general 
stomatitis catarrhalis, the least irritant will produce a partial 
or general return of the trouble, so that in badly-nourished 
marantic children the condition becomes chronic. In healthy 
children this is not the case, although in them a running down 
is apt to be followed by another attack, provided the external 
causes are present. Infants are more liable to this disease than 
older children, although in the latter it is by no means un- 
common, being overlooked in them on account of absence of 
symptoms. 

Treatment. — The importance of conscientious treatment is to 
be found in the fact that this disease may be the forerunner of 
other more serious troubles, as has already been pointed out. 
As a rule, a general catarrhal stomatitis runs a favorable course 
without any special treatment. Indeed, it must be taken for 
granted that this is the case in the great majority of instances, 
as the better class of children, only, are under such strict sur- 
veillance as to be placed under the care of a physician whenever 
a slight ailment exists. It is impossible to enter into such 
details as would cover the whole ground in each individual 
case; this is fortunately unnecessary, as after all the principles 
of treatment are the same whether applied to an inflammation 
of the mouth or any other part of the body. 

Prophylaxis is highly important; with nurses we usually 
find the two extremes in the care of the mouth of infants. 
They are either oblivious of the necessity of looking after the 
mouth, or they treat it with such violence as to do more harm 
than good (see chapter on Bednar's aphtha?). The rough finger 
of the rougher nurse is used as the means for cleaning the 
mouth, — perhaps wrapped in a diaphonous handkerchief, — and 
this is pushed into the unoffending mouth, scraping away every- 
thing with which it comes into contact. Or the mouth is 
never examined ai all, and, much to the surprise of every one, 
there develops suddenly a stomatitis of one kind or another. 



30 DISEASES OF THE MOUTH (NON-SURGICAL). 

Under normal circumstances, the mouth of every infant ought 
to be washed out several times daily with lukewarm water 
which has been previously boiled. A small wad of absorbent 
cotton, wrapped upon a smooth stick or wire, is as good a con- 
trivance as any, as it insures cleanliness and, with reasonable 
care, is perfectly safe. For infants and restless children the 
cotton can be wrapped around the finger of the nurse. The 
rule must be laid down as absolute that the cotton must be re- 
placed by a fresh piece every time the cleansing is done. A 
large camel's-hair brush is more convenient but not so safe, as 
far as being the possible carrier of infection. Mothers must 
be taught to regard cleanliness in the mouth as of the same 
importance as upon the external surface. For this reason they 
must be taught to keep their nipples in good condition, and 
if the child is brought up artificially, how to take care of 
all of the various articles necessaiy to artificial feeding. The 
quality and physical properties of the food, in the latter in- 
stance, must be especially dwelt upon, notably the temperature. 
In older children, the tooth-brush will frequently prevent at- 
tacks of localized stomatitis. All irritating substances which 
act as foreign bodies, such as sharp teeth, accumulations of so- 
called tartar, perialveolar abscesses, etc., must be treated and, 
if possible, removed. In the course of febrile affections much 
can be done to prevent affections of the mouth, which, unfor- 
tunately, are still too common. If the patient is old enough 
he can be taught to suck small pieces of linen which have been 
dipped into ice-water or in which small pieces of ice have been 
wrapped. The sordes, cracked tongue, etc., of continued fevers 
can be easily prevented by a moderate amount of care. If we 
are dealing with a young child or one delirious, frequent wash- 
ing of the mouth with cold water will accomplish the end 
almost as readily. Either of these plans is both grateful and 
beneficial to the patient; grateful, especially, in that it relieves 
the thirst which is always present with high fever. 



STOMATITIS CATARRHALIS. 31 

The treatment of the affection, once the cause is removed, is 
a very simple matter. All food must be given cold, — it causes 
less pain to the patient and reduces the swelling of the mucous 
membrane. If necessary the milk can be cooled by putting 
the vessel containing it into ice. This, however, is purely em- 
pirical, as some children with stomatitis catarrhalis bear their 
food better when it is quite warm. In children at the breast 
this falls away, of necessity, as it would be reprehensible to 
change the food on account of the benefit which might accrue 
by having its temperature reduced. The mouth must be gently 
washed, as often as possible. Cold water — ice-cold if necessary 
— which has first been boiled is, as a rule, sufficient. As lotions 
a great many substances have been used : boric acid (two- to 
three-per-cent. solution), sodium biborate (five to ten per cent), 
zinc sulphate (one-half to one per cent.), salicylate of sodium, 
salol, etc. Most, if not all, are unnecessary except as to the 
probability of directions being followed more exactly when a 
mouth-wash is prescribed. The internal or external use of 
potassium chlorate is also unnecessary and, according to my 
experience, valueless in this form of trouble. Unless absolutely 
indicated, potassium chlorate ought not to be used, on account 
of the risks attending its administration ; it does not seem 
necessary to take any risks in the treatment of a simple stoma- 
titis. The most reliable of all medicaments is silver nitrate 
(one-half to one per cent.). If the stomatitis does not disap- 
pear in three or four days, the mouth ought to be pencilled 
with this weak solution of silver nitrate once a day. Before 
applying the solution the mouth must be carefully washed out 
with cold water. Whenever there is a loss of epithelium, or 
an ulcer, the mitigated slick should be used. A small quantity 
melted on to a silver probe forms an excellent weapon for 
fighting these apparently insignificant but very painful lesions. 
It is no uncommon experience to find a child taking its food 
again after a small erosion has been touched with this substance. 



32 DISEASES OF THE MOUTH (nOX-SURGICAl). 

The larger ulcers, especially, are to be treated in this manner. 
Cysts must be opened, the sooner the better, by a free incision. 
If they should fill up again, cauterization of their walls should 
be resorted to. The treatment of those forms due to dentition 
will be discussed in the proper chapter. 



STOMATITIS APHTHOSA. 33 

II. 

STOMATITIS APHTHOSA. 

In discussions on this subject we find confusion most dire. 
In looking through the literature it will be found that so 
many things are called aphthae, and so many tilings have 
been called aphtha?, that but one of two courses remains to be 
taken, — either the term aphthae must be discarded entirely, or 
we must make our definition of the term so precise that mis- 
take is impossible. As has been pointed out before, the term 
comes from Hippocrates, and gradually it has been made to in- 
clude nearly every affection of the mouth ; thus, even modern 
books speak of it as synonymous with thrush or the ulcerative 
form. The first who gave us a definition for the modern ac- 
ceptation is Bil lard ("Maladies des Enfants," p. 230 et seq., 
Paris, 1837), where a complete discussion of the history of the 
subject may be found. Billard speaks of a stomatite follicu- 
leuse on aphtes, but the adjective is to be construed more as 
referring to the form of eruption than to its location. To Bohn 
is due the credit ("Die Mundkrankheiten der Kinder," 18GG) of 
having placed exact limits to our conception of what should be 
meant by aphtlue. It must be remembered, in this connection, 
that tin; accepted term has an entirely different significance 
from that which Hippocrates intended, — he, in all probability, 
had reference to the mycotic; form only when he speaks of 
Hf&ac, As a result, some modern authors still speak of aph- 
thous sore mouth as thrush; but, unfortunately, whenever this 
is done a description is given which shows very clearly that 
tic author is describing several forms under one heading which 
have no possible connection with each other. If all authors 
would unite ami give to the term aphthous or aphtlue (either 
adjective or noun; the Hippocratic sense there certainly could 



34 DISEASES OF THE MOUTH (xoX-SUTtGICAL). 

be no objection raised. But as it is, the two courses before men- 
tioned are the only ones possible. As far as rejecting the term 
altogether is concerned, Bohn has done so much to establish 
the identity of the affection, and it has been taken up by so 
many authors (all the German, some of the French, English, 
and American), that it would seem like taking a retrograde 
step to drop the term. In addition, the confusion that already 
exi.-ts would be increased, and that which has been gained 
by precision would be lost. As a result the term stomatitis 
aphthosa has been retained to mean that form of disease de- 
scribed by Bohn. 

Definition. — By aphthae are meant spots, of different color, 
appearing within the mouth, situated under the epithelium, 
surrounded by an areola, again of varying color, which run a 
peculiar course during their existence. As far as the nature of 
these spots is concerned there still exists considerable discussion. 
There are principally two opinions expressed. The one, that 
we are dealing with a vesicular eruption ; the other, that we are 
dealing with a solid exudation between the cutis and epithe- 
lium. The great objection urged against the former view by 
Bohn and his followers, that they have never seen any fluid 
within the spots, is, apparently, a very valid one. But if we 
take as simple a matter as herpes, it will be seen that if we were 
to judge this eruption by the presence or absence of fluid within 
the efflorescences we might, in a great many cases, be led to 
the conclusion that herpes is also a solid exudation between the 
cutis and the epithelium. If to this there is added the fact 
that all forms of skin-trouble do and must, of necessity, take 
upon themselves a different form within the mouth than upon 
the skin, a great deal of the force of Bonn's argument is lost. 
It certainly must be accepted as a fact that the epithelial layer 
is regenerated much more rapidly within the mouth than any- 
where upon the surface of the body. This, taken together 
with the constant bathing with fluids, under pathological 



STOMATITIS APHTHOSA. 35 

conditions even greater than in health, and the great disparity 
that exists between the two views can be readily cleared away. 
When we come to compare the clinical history of some forms 
of herpes and of stomatitis aphthosa, it will be found that the 
view which makes both processes due to the same causes is, to 
say tlie least for it, very enticing. When, added to this, there 
is a series of carefully-conducted bacteriological investigations 
which give a negative result, as far as pathogenic organisms 
are concerned, we will have to think even more seriously of 
this view. 

As far as locality of eruption is concerned there can be but 
one opinion, Aphthae appear in parts of the mouth in which 
there are no follicles; therefore the eruption cannot be fol- 
licular in the sense that it is the result of some process which 
goes on within the muciparous glands. This, on the other 
hand, d«»es not prevent our acknowledging the fact that an 
aphthous eruption may appear at the mouth of a follicle any 
more than our accepting the fact that an herpetic eruption may 
develop at the opening of a sebaceous follicle or sweat-gland. 
Yet no one would think of calling herpes a follicular eruption. 

Again, concerning the term aphthous ulcer, to which Bohn 
objects SO strenuously. This depends entirely upon what may 
be defined as an ulcer; if there is necessary both a disturbance 
of continuity and the appearance of pus we can certainly not 
speak of the existence of an aphthous ulcer, as it is exceedingly 
rare to find pus in appreciable quantity the result of aphthous 
stomatitis. If we go further and accept Billroth's view, that 
the appearances in the intestines in typhoid fever must nol be 
considered aa ulcera because they have a tendency to heal (it 
being absolutely indispensable for an ulcer not to have the 
tendency to get well), then we can certainly not speak of the 
epithelial sores made by aphtha; as ulcers. < >n the Other 
hand, the local conditions referred to above must be again 
taken into consideration. We nm-t also bear in mind that we 



36 DISEASES OF THE MOUTH (xoX-SUEGICAL). 

are dealing with a term which is used with more or less free- 
dom by the profession, and although, theoretically, such a loss 
of substance as is produced by an aphtha is not an ulcer, yet, 
for all practical purposes, it must be considered as such. As 
will be seen farther on, the epithelial loss produces symptoms 
just as well marked and as intense in their nature as if pus 
were being formed, or as if there existed a tendency to spon- 
taneous healing. 

Etiology. — Concerning the etiology of this affection we are 
completely in the dark, as far as positive knowledge is con- 
cerned. A great many views have been expressed and a great 
many things have been brought into causal connection with 
stomatitis aphthosa, but as yet no lesion has been discovered 
beyond those which will be described and which are absolutely 
inconclusive. The cause must besought for either in the mu- 
cous membrane itself or in structures remote from it. As to 
the mucous membrane, there are many causes which might pro- 
duce an eruption upon it of the nature described before. By 
means of applying caustics it is possible to imitate the appear- 
ance and course of aphtha? in the mouth (Gerhard t, Bohn). 
I have seen burns in the mouth, produced in one instance by 
the head of a burning match, which it would have been im- 
possible to differentiate from aphthae. But such external 
causes can be disregarded, as the eruption appears without 
any apparent external cause. It is natural that lower forms 
of life should have been accused of causing this trouble; but 
I have had eight cases of stomatitis aphthosa examined into 
by two most competent observers, Drs. Cameron and Free- 
man, demonstrators of bacteriology in the Medical College of 
Ohio, Cincinnati, with an absolutely negative result, as, after 
the most careful search, including plate- and tube-culture, only 
pus-formers were found. These were found in two out of the 
eight cases, and must, therefore, be looked upon as accidental. 
It can therefore be conclusively accepted that there exists no 



STOMATITIS APHTHOSA. 37 

localized cause in the mucous membrane. But one structure 
or structures remote from the mucous membrane could be 
accused of producing aphthae, — the nervous system. Bohn 
shows that the greatest number of cases occurs between the 
tenth and thirtieth month after birth. Because the teeth come 
through about this time, and because proruption of a tooth is 
frequently accompanied or followed by aphtha?, he comes to the 
conclusion, which is not unwarranted, that the process of teeth- 
ing has something to do with stomatitis aphthosa. We find 
aphtha? associated with any number of diseases, — pneumonia, 
ague, gastro-intestinal catarrhs, the acute exanthemata, etc. 
If there exists any connection between teething, pneumonia, 
ague, etc., and stomatitis aphthosa, bacillary origin being posi- 
tively excluded, it must be through the nervous system. This 
view has been expressed by Barensprung, who thinks that 
some forms of herpes facialis may be due to lesions in smaller 
ganglia, just as herpes zoster is due to lesions in the spinal 
ganglia. There are objections to the acceptance of this view, 
however, as the eruption is not localized anatomically, as in 
herpes zoster, and frequently it is too general to be explained 
by the affection of one or two nerves. That an eruption can 
be produced by affection of nerves or nerve-centres is a fact ac- 
cepted by dermatologists (Kaposi, Sattler, etc.). The eruption 
thus caused is herpes, and when herpes appears in the mouth 
it is "stomatitis aphthosa." Bohn, who in the beginning of 
his excellent article insists on the non-existence of vesicles, at 
the end of his chapter compares aphthae with eczema or im- 
petigo. Anatomically speaking, eczema is a process character- 
ized by serous exudation and impetigo by purulent exudation. 
No one could claim that aphtha are characterized by either of 
these two products, and when eczema does appear upon a 
mucous membrane (of* the nose) there is no difficulty in recog- 
nizing it ;ts sudi and no hesitation in separating it from an 
aphthous eruption. The facl thai aphtha? may be found in 



38 DISEASES OF THE MOUTH (NON-SURGICAL). 

children with impetigo is of no possible value as establishing 
any connection between them. If we grant that aphthae come 
out in groups (which will be shown to be the case), and if we 
admit that a vesicle in the mouth would present all the charac- 
teristics of an aphthae, we are forced to the following conclusion : 
aphthae' are eruptions characterized by vesicles which appear in 
groups. This, it will be seen, is an exact definition of herpes. 

Occasionally cases are reported in which the evidence seems 
to point to the contagiousness of this form of affection. There 
is no doubt that two or more cases will sometimes happen in 
the same family. Careful inquiry will almost always result in 
establishing the fact that the aphthous process is produced in 
these cases by the same cause; that the aphthae are due to a 
disease, endemic or epidemic, which has attacked the various 
members of a family. In some instances we may be lefD en- 
tirely in the dark concerning the nature of an apparent epi- 
demic ; but the fact must not be lost sight of, that stomatitis 
aphthosa is a conglomeration of symptoms the exact nature of 
which eludes discovery. 

The attempt has been made to bring this disease into rela- 
tion with the hoof-and-mouth disease of cattle. If this should 
be proved in every instance, hoof-and-mouth disease must be 
very much more common in cattle than we have any reason to 
suppose. The possibility of a connection cannot be denied, 
and, if proved, would place aphthae among the infectious 
diseases. Certain it is, however, that the cases which have 
come under my observation and the eight cases examined, men- 
tioned above, were not of this nature. Cnyrim (Jahrbrh. f. 
Kinderheilkunde, N. F., xxiii.) reports an outbreak of hoof-and- 
mouth disease among the cows of the Model Dairy at Frank- 
furt-am-Main. The attempt was made to determine whether 
drinking the milk from the diseased cows had the effect of pro- 
ducing aphthae, but the results were unsatisfactory. Fifty- 
three physicians answered questions relative to their patients 



STOMATITIS APHTHOSA. 39 

who took milk from the dairy ; out of this number twelve 
noticed eruptive diseases in the patients. In eight of these 
no connection existed between the milk of the dairy and the 
eruption, as the patients took milk from other cows. In the 
remaining four one physician reports herpes of the upper lip 
and throat, another reports two cases of skin affection, another 
vesicles upon the mouth and lips, and a fourth two cases of 
stomatitis aphthosa. So that, after all, there are but two cases 
left, and the final conclusion of the author seems justified, 
"that those consumers who remained true to the dairy did not 
suffer," which is the same result arrived at in the epidemic of 
1877.* 

Symptomatology. — Setting aside whatever general disturb- 
ances may be concomitant with the disease upon which aphthae 
are engrafted, the symptoms are principally confined to local 
niaii i Testations. Preceding the eruption of aphthae there is 
usually present more or less stomatitis catarrhalis. This may 
be due to the disease producing the stomatitis aphthosa (mala- 
ria, pneumonia, etc.), or may be produced by the aphthous pro- 
cess itself. We find an analogue in herpes zoster facialis when 
the gums or cheeks become affected, and redness is always 
present even if no distinct eruption appears. 

The aphtha? appear with lightning rapidity. A mouth 
which has been examined and found slightly reddened will, 
the next day, have an extensive eruption of characteristic 
lesions. These consist of small subepithelial whitish or yel- 
lowish-white spots, appearing singly or in groups, which may 
develop in any part of the mouth. They are not unilateral 
ami, probably, are not confined to the cavity of the mouth 
(they not infrequently extend into the pharynx). The erup- 

* The author baa taken pains to examine cows supplying milk to 
patients affected with stomatitis aphthosa, always with negative results. 
He baa further been told by veterinary Burgeons that few, if any, cases 

Of foot-and-mouth disease have occurred among cows in this country. 



40 DISEASES OF THE MOUTH (xOX-SURGICAL). 

tion as such is very short-lived,— after from twelve to thirty- 
six hours the epithelial covering is soaked off, and there is left 
the so-called aphthous ulcer. This is characterized by its out- 
line, formed by a slight depression surrounded by a red mar- 
gin (the latter also present in the former state), and its floor 
being lined by the original contents of the vesicle. Where 
two or more aphthae have developed close enough to each other, 
we find the ulcer becoming serpiginous, in that two or more 
have run into each other. After a few days more the epithe- 
lial layer begins to be regenerated, the small mass at the bottom 
of the ulcer is enclosed by this layer encroaching upon it from 
all sides, it is lifted up and projects beyond the level of the 
mucous membrane, and finally disappears. Or the floor of 
the ulcer is cleared, the exudation being washed away, and 
there is left a surface denuded of epithelial cells, which will 
bleed only when rudely touched. Again, some aphtha will be 
absorbed without the outer epithelial layer breaking. When 
there are complications (stomatitis ulcerosa) the aphthaa some- 
times become infected, and then we have a true suppurative 
process going on. As a rule, the aphthse appear in crops, — 
the one succeeding the other, — so that the course of the disease 
may become somewhat protracted, — ten to fourteen days. Cases 
lasting beyond this time are much rarer in children than in 
adults. 

The exudation as it is found in the ulcer will be found to 
be made up of small, indifferent cells, some fibres, and several 
varieties of lower forms of life usually found in the mouth, 
but not pathogenic. All the cases examined into were free 
from pathogenic forms which could explain the occurrence of 
the eruption. 

The denudation of the epithelial layer is covered up with 
new cells and no cicatrix is left, because the connective tissue 
is not affected. The young epithelial cells are at first opaque, 
so that a white spot is left where the aphtha was ; in a short 



STOMATITIS APHTHOSA. 41 

time, however, this disappears unless the process was compli- 
cated by some other form, when a slight scar remains. 

While this whole process is going on the subjective symp- 
toms vary enormously. Some children are very little affected 
by stomatitis aphthosa; indeed, as a rule it is only the de- 
nudation and its contemporary irritation and reaction which 
produces symptoms. These are the same as described under 
stomatitis catarrhalis, — salivation, pain, restlessness, loss of 
appetite, etc. Bohn lays especial stress upon the fact that the 
saliva in stomatitis aphthosa is not fetid. This can be verified 
in every instance, unless a complication exists with stomatitis 
ulcerosa, which is not very rare. In some instances the erup- 
tion is so extensive that the whole mouth is covered with it 
and produces the picture of a diphtheritic inflammation. If 
differential diagnosis is not possible in the first instance, a 
day of waiting will clear up the whole picture, as by that time 
some of the spots will become denuded and symptoms of 
general infection will have appeared. 

Prognosis. — This is absolutely good. The same that holds 
good for stomatitis catarrhalis is also true here. We are 
dealing with a self-limited disease, which does no harm except 
in that it may affect the general health of the patient. As 
far as the local trouble is concerned, in an otherwise healthy 
child, stomatitis aphthosa is to be looked upon as a painful 
but harmless affection. It is barely possible for the ulcers 
produced by this disease to become infected with other poisons 
(some cases reported by Schrakatnp are possibly of this nature), 
but this is, fortunately, of rare occurrence. Good or bad general 
conditions of health seem to have very little to do with the 
frequency of the eruption, — it is very easy to say that rachi- 
tic, Byphilitic, badly-nourished, etc., children are more liable 
to aphthse than healthy ones. Beyond the fact that this form 
of trouble is concomitant with a great many acute diseases 
these statements are perfectly gratuitous and require to be 



42 DISEASES OF THE MOUTH (NON-SURGICAL). 

proven. A form of chronic ulcers seen in adults is very 
rare in children. These are catarrhal in nature, come and go, 
last for a long time, and are usually accompanied by general 
disturbances. It is a mistake, however, to call these ulcers 
aphthous, as they do not possess any of the characteristics of 
aphtha, not the least important, for the latter, being their 
tendency to spontaneous healing. These chronic catarrhal 
ulcers have been confounded with aphthae, and what is true for 
them has been ascribed to the aphthous process. For the ex- 
planation of their general constitutional effects we refer to the 
previous chapters. Relapses are not common in children after 
the affection is once healed, another evidence that the general 
condition has little to do with the appearance of this erup- 
tion. It will occur that in a reduced child the process does 
not have a tendency to get well,— just as an ulcer upon the 
skin under the same conditions would not heal. In such cases 
these ulcers, as has been indicated before, may give rise to a 
great deal of trouble. 

Treatment— The object of treatment is to give relief from 
pain and prevent infection. The former, and possibly the 
latter, is accomplished by touching each ulcer with nitrate of 
silver. The treatment is identical with that recommended for 
catarrhal ulcers and gives just as much relief. I have never 
had good results from cocaine, recommended by some authors 
in troubles of the mouth (Bockhardt, Monatsheftef. Dermatol, 
v. ii., 188G), and would hesitate to employ the very strong solu- 
tions (ten to twenty per cent.) recommended. Baginsky speaks 
very highly of permanganate of potassium (0.10 to 15.00) and 
considers it almost a specific, curing the affection in a short 
time (wenigen Tagen). Chlorate of potassium is unnecessary, 
as much so as the great number of external remedies that have 
been vaunted and applied. The same rules for diet put down 
in the previous chapter also apply here. The fact must never 
be lost sight of that a pure, uncomplicated case of stomatitis 



STOMATITIS APHTHOSA. 43 

gets well of its own accord, and all the physician need do is to 
watch, give relief, and prevent any complications by hygienic 
measures. 

bednar's aphtha. 

In 1850, Bednar's small but, clinically, very valuable book 
appeared, in which was described a peculiar form of lesion of 
the mouth, which has since been accepted as Bednar's aphthae 
(" DieKrankheiten d. Neugebornen u. Sauglinge/' etc. Vienna, 
1850). He states that this form is only found in infants from 
the second day after birth to the age of six weeks. There are 
five different forms, characterized by the locality and nature 
of the eruption, — the first three are found upon the hard palate, 
the fourth upon the soft palate as well, and the fifth is hemor- 
rhagic. They are preceded by an injection of the mucous 
membrane, and then follows an exudation, gray or yellowish- 
white, subepithelial. This breaks down and leaves an ulcer. 
They are found iu the posterior portion of the hard palate 
either on one side (first form), symmetrical (second form), or 
combined with one upon the palatine suture, but always near 
the velum palati. Such, in brief, is Bednar's description. It is 
not difficult to see that a great many processes may run their 
course and give rise to symptoms akin to those described. Such 
is the case, and we find at least three different conditions, per- 
haps more, which it is impossible to distinguish the one from 
the other. There is that process which is found in the mouths 
of newly-born infants as well as upon their skins, the develop- 
ment of mil ia ; when these ulcerate from one cause or another, 
they give rise to appearances similar to the aphthae of Bednar. 
There are retention cysts, very small, like acne, which may also 
be followed by ulcerations (Bohn). Epstein claims that small 
defects, congenital, exist in the mucous membrane filled with 
epithelial detritus which simulate Bednar's aphth:e. The same 

author states that true ulcers, produced by decubitus, may occur 
upon a mucous membrane affected by catarrhal stomatitis caused 



44 DISEASES OF THE .MOUTH (NON-SURGICAL.). 

by nursing. For this lie gives an anatomical explanation in 
that the part of the mucous membrane affected becomes most 
tense and anaemic during the act of nursing, and therefore 
more liable to be affected by pressure than any other part. 
Comparatively recently Fischl (Pray. Med. Wochensehrift, xi. 
41, 1886) has made observations which throw some light 
upon the etiology of Bednar's aphtha?. He took a large 
number of children in the Foundling Asylum at Prague and 
divided them into three groups. In the first group the mouth 
was left alone, not washed nor cleansed in any way ; in the 
second group the mouth was washed and cleansed regularly; 
and in the third no especial attention was paid to the matter, 
so that some were and some were not washed out. The result 
was that in the first group five per cent, were affected, in the 
second fifty-four per cent., and in the third fifteen per cent. 
The ulcerations of the soft palate were also noticed most 
frequently in the second group. It seems, then, that the most 
common cause for these aphtha? is violence; and the statement 
will certainly be borne out by the experience that, when this 
form of trouble is noticed at all, it is much more common in 
hospital than in private practice. In private practice the nurse 
is under the observation of the mother, in hospital practice she 
is apt to be too zealous in the performance of her duty; when 
she is ordered to keep the mouth of a patient clean, it is done 
hurriedly and, perhaps, not too gently. The ulcerations upon 
the velum are just in the locality where the end of the finger 
would touch when introduced into the mouth, and those upon 
the hard palate can be explained just as readily by the sweep- 
ing motion of the back of the finger. While it cannot be 
denied that these aphtha? may arise spontaneously in any of 
the ways indicated before, it must be confessed that the origiu 
by violence must be looked upon as the most common.* 

* Ulcers far forward, upon the hard palate, are not infrequently pro- 
duced by the rubber nipple in artificial feeding. 



STOMATITIS APHTHOSA. 45 

Again, these ulcers are self-limited; their tendency is to get 
well. The symptoms produced are those of pain in nursing 
only, and the consequences of not taking food. They are apt 
to be complicated by the development of thrush, and some- 
times (as in two cases of Fischl, he. cit.) may terminate fatally 
by producing gastro-intestinal disturbances when they persist 
for too great a length of time. The term is used as a clinical 
one, just as it was used by Bednar; it represents a clinical 
picture, produced in different ways, and his description is just 
as true to-day as it was when he first published it. 

Treatment. — Bednar says, " The disease cannot be shortened 
by any remedy, and in the absence of any dangerous compli- 
cations its termination is always favorable; therefore it is 
superfluous to paste the mouth with mucilago or to wound it 
with caustics." The disease is rare in this country, but it does 
occur. In the cases that I have seen I have remembered Bed- 
nar's injunction, and they have all recovered without any 
untoward symptoms. Those complications that may arise 
must be treated as such, but it is unwise to do more than is 
already being done in the effort to repair damage resultant 
upon various causes. The most common complication is stom- 
atitis mycosa, which can be easily avoided and just as easily 
treated. The general disturbances, dyspepsia and intestinal 
lesions, must be overcome and the general nutrition of the 
infant must be watched. 



46 DISEASES OF THE MOUTH (NON-SURGICAL). 



III. 

STOMATITIS MYCOSA. 

Synonymes. — Thrush, Soor, Mundschwiimmchen, Muguet. 

The nature of this disease, now so clearly understood, was 
entirely unknown until the parasitic growth which causes it 
was discovered. On account of the fact having been thoroughly- 
established, and because the life history of the parasite is com- 
paratively well known, thrush becomes one of the diseases 
which can be looked upon as a paradigm by which other in- 
fectious diseases can be regulated. 

The historical development of the subject may be divided 
into two periods, — that before the discovery of the cause of 
the disease (about 1840) and that following this date. In 
the first period we find the older writers, and especially the 
French authors. It is almost a certainty that Hippocrates 
described thrush under the heading of ari'iuaza ac>'twd-a, and 
Galen was also acquainted with the affection. The authors 
following them looked upon the affection either as ulcerative 
(Avicenna) or vesicular, papular or pustular (Boerhaave, Rosen 
v. Rosenstein). Rosen (German edition, translated and edited 
by Murray, professor in Gottingen, 1774) has, like all his 
predecessors and a great many of his successors, described 
many forms under the head of " Schwammgen." He has 
evidently seen cases of diphtheria which he writes about, pos- 
sibly some other forms of stomatitis, but, without doubt, cases 
of thrush. He has made accurate observations in connection 
with the latter, — about the effect of cleanliness, the possibility 
of producing irritation of the nipples of the nurse, a connec- 
tion between gastro-intestinal troubles and the sore mouth, 
— and advises the use of some remedies which, it is strange 



STOMATITIS MYCOSA. 47 

to say, are still favorites with some authors on children's dis- 
eases (rhubarb and magnesia !). 

In 1786 the Societe Royale de M&lecine offered a prize of 
twelve hundred livres on the causes of the disease known as 
" millet, blanchet, muguet" (thrush). This was done because of 
the fact that so many children were dying of the affection at the 
Hopital des Enfants. The prize was divided between four, out 
of six competing, one of whom, Van Wimperse, succeeded in 
localizing the affection anatomically. This was, as Bohn states, 
the first attempt to describe the disease as an independent affec- 
tion, and the result was an impetus given to observation in a 
different direction from that of former authors. After 1826, 
when Brctonneau first described diphtheritis, a name which he 
afterwards changed to diphtheria, it was held by a great many 
French authors that thrush was diphtheritic in nature, and 
even to the present day we still find French writers speaking 
of a "stomatite pseudo-membraneus'e" when the invasion of 
thrush is very extensive. From this time until the discovery 
of the cause of the disorder very little progress was made 
beyond the discovery that the disease did not limit itself to 
children, but was also found in adults suffering with lingering 
or wasting diseases. The result was that great stress was laid 
upon this fact, the local nature of the disease was overlooked, 
and the fearful mortality spoken of by Valleix (" Clinique 
dee Maladies des Enfants nouveau-nes," 16, 1838) — twenty 
cases dying out of twenty-two — ascribed entirely to this af- 
fection. This view, somewhat remodelled, was again taken 
up by Parrot (1874), who ascribed the predisposing cause of 
thrush in all instances to the condition he calls athrepsia, a 
view which, it will be seen, is altogether untenable. We now 
come to tin.- second historical period, in which the cause of 
1 1 1 it i-l i was firsi discovered. There are a great many ob- 
servers who saw the mould, but to Berg, of Stockholm, is 
given the credit of first having observed it, at least of fust 



48 DISEASES OF THE MOUTH (NON-SURGICAL). 

having described it accurately and making experiments with 
it, showing its nature, the possibility of cultivating it, and its 
inoculability. His description is the one to be found in most 
works and articles upon the subject of thrush ; but Robin (1853, 
"Histoire Naturelle des Vegetaux Parasites") first named the 
vegetable parasite "o'idium albicans," a name still employed, 
although subsequent observers have been unable to classify the 
growth under this heading. The old name is now chiefly used 
by French authors (Fossanngrives, Simon), who continue to 
quote the older experiments, although progress has been made 
since Robin. Grawitz (Virchow's Archiv, 1877, p. 546 et 
seq.), following the methods indicated by Brefeld, was the first 
to study the thrush fungus according to modern ideas, and 
with the following results: he obtained pure cultures in a 
fluid made up of a solution of glucose, one per cent, of am- 
monium tartrate, and mineral salts obtained by making an 
extract of cigar-ashes. He also used a decoction of baked 
plums or currant jelly diluted with equal parts of Pasteur's 
liquid. In these fluids he demonstrated that the thrush fun- 
gus could be cultivated, but only in a peculiar state, — that of 
spores with the mycelium badly developed ; the more sugar 
there was present the greater the number of spores; the more 
salts, the greater the number of threads. From these he made 
pure cultures, and came to the conclusion that the yeast-cell 
or spore was the forerunner of the mycelium, and according 
to the nature of his fluid he could cultivate thrush fungus 
rich in mycelium or made up principally of spores which re- 
sembled yeast-cells. There are two ways, then, in which the 
fungus grows, — one from clusters of gouidia attached to the 
mycelium, another from free spores. He then states that the 
fungus of thrush is not oi'dium albicans but the ordinary my- 
coderma vini, which produces a fermentation and which grows 
upon fruit juices, but only in the form of spores. Grawitz 
then furnishes the proof of his having described the thrush 



STOMATITIS MYCOSA. 49 

fungus by taking a pure culture of the ravcoderraa vini and 
producing thrash in five young dogs which were fed upon 
cow's milk. About the same time Reess published his obser- 
vations (quoted from Bohn), in which he comes to the con- 
clusion that the thrush fungus is not an oidium but a 
saccharomyces-producing fermentation. He was not able to 
convert the mycoderma vini into a thrush-producing fungus 
or vice versa, and therefore proposes the name saccharomyces 
albicans until the exact relation of mycoderma and the thrush- 
producer is positively settled. A. Baginsky (Deutsche Med. 
Wochenschrifi, 1885, p. 8GG) has made some experiments by 
means of plate cultures on meat peptone, gelatin, and pota- 
toes, which were considered pure cultures by Koch. On pota- 
toes he obtained the yeast form, on bread the same, especially 
upon the surface, and very little mycelium. In test-tubes the 
surface proliferation was that of yeast-cells, while in the deep 
it was in the form of mycelium. He does not think the fun- 
gus is mycoderma, and mentions Stumpf (whose publication I 
could not obtain), who thinks that the fungus is a mixed one, 
made up of oidium and yeast. Plaut (1887) completely disa- 
grees with Grawitz, and claims that the plant is the monilia 
Candida; he comes to the following conclusions: The plant 
doe-; more harm in its mycelium form ; it does not develop 
upon healthy mucous membrane; and, lastly, the best treat- 
ment is corrosive sublimate, applied in the strength of one 
part in a thousand of water. G. Roux and Linossier (1890) 
show why so much confusion exists, but up to the present the 
position of the fungus has not been accurately defined. Ac- 
cording to these observers, pure cultures can be obtained in 
Esmarch tubes or by plate culture, and, in forty-eight hours 
at I 5° to 20 ' ( '., before Other colonies of mouth microbes have 

appeared, colonies develop that are made up entirely of yeast- 
cells. The enclosing membrane of the cells does not have 

tie- cellulose reaction ; the protoplasm, at first, is hyaline and 



50 DISEASES OF THE MOUTH (XQN-SURGICAL). 

homogeneous, but becomes vacuolated and has small mobile 
granules. Like other microbes, basic aniline dyes are taken 
up with great avidity, but the cells are not decolorized after 
using Gram's liquid. There is no nucleus, the nuclear sub- 
stance being in a diffuse state throughout the protoplasm. 

The yeast form is always produced upon neutral or slightly 
alkaline, peptonized gelatin, and this form can be confounded 
with any one of the saccharomyces. This is the mature form 
which is modified according to the food upon which the fungus 
develops. Budding goes on with very great activitv, espe- 
cially upon solid substances like carrots, apples, etc., produc- 
ing torula forms, "veritable bouquets of yeast-cells/' which, 
under favorable circumstances, increase in size. Some of these 
cells become filamentous and then all the forms between the 
yeast and the globulo-filamentous can be observed. The pro- 
duction of filaments goes on in two ways: one, by the produc- 
tion of a daughter cell, which becomes a filament; and the 
other, by the pushing off from the mother cell of a proto- 
plasmic process which is separated only when the thread is 
thoroughly formed. The latter process can be mistaken for 
spore formation, but by careful observation this can be ex- 
cluded, as both processes go on in the same specimen, and their 
comparative frequency depends upon the nature of the culture 
medium. Under all circumstances, we no longer have the 
right to call the globulo-filamentous form, mycelium, and the 
yeast form, conidian, as both of them form spores, and there- 
fore both have a right to the appellation of mycelium. They 
are different aspects of the same cell, depending upon the 
culture medium, so that one culture may be made to produce 
all the intermediate forms. 

Two distinct kinds of elements are produced by the budding 
of these threads ; the yeast form and new threads. The latter 
do not take part in reproduction, but disappear rapidly when 
a new culture is made: no purely filamentous form has ever 



STOMATITIS MYCOSA. 51 

been obtained, though cultures upon gelatin peptone with cane- 
BUgar approach very near to this condition. 

Cultures upon boiled carrots in Roux tubes are best for a 
study of the fungus. At first there is a tendency to the pro- 
duction of filaments, but after forty-eight hours yeast forms 
alone are found, which persist; the filaments being found only 
in the deeper layers in contact with the carrot. Everything 
else being equal, solid media are better for the development 
of the fungus than liquids. 

No ascospores are funned ; therefore, according to these ob- 
servers, the fungus is not a saccharomyces ; the chlamydospore, 
which is observed, has been seen in its various stages by others, 
but never been thoroughly appreciated: for the purpose of 
studying this Nageli's fluid No. 1, with one to five per cent. 
of saccharose, is the best medium, and in cultures far removed 
from the original from the mouth. These spores differ from 
all other portions of the fungus in their micro-chemical reac- 
tions as well as in their appearance. They react differently to 
methylene blue, osmic acid, and eosin. When they first make 
their appearance their contours are well rounded, their proto- 
plasm is less hyaline than that of the conidia, and their mem- 
Inane is thicker. They attain their maximum growth in 
forty-eight hours, and are three to four times as large as the 
yeast forms; they are spheres with a very thick lamellated 
tonic, enclosing granular, punctate, and proliferating proto- 
plasm. The cells to which these spores are attached have 
been call'd preterminal by the author; the three or four 
nearest to the spore contain glycogen; the spores themselves 
show, with the iodine reaction, alternate layers of brown and 
yellow, which, during development, disappear to give way to 
a uniform reddish tint. 

The chlamydospore contains a central body which can be 
forced out of the capsule by pressure; this is made up of 

granule- po-.~c~-.iug Brownian movements, arranged around a 



52 DISEASES OF THE MOUTH (xOX-SUKGICAL). 

larger body, the latter not taking up ordinary coloring matter. 
During life it was found that the granules began to disappear, 
the body around which they are arranged to increase in size, 
and to become surrounded by a membrane; coincident there is 
a complete disappearance of glycogen and protoplasm in these 
preterminal cells. The results of these biological researches 
are that thrush is propagated in three ways: (1) in the fila- 
ment formed by conidia ; (2) in the yeast form, by isolated 
conidia; and (3) by spores. It cannot be proven by direct 
observation that the chlamydospore takes part in propagation, 
but on account of its presence the fungus is not a saccharo- 
myces nor is it monilia Candida. Cells of involution, pseudo- 
sporangia, are also found, which may give rise to confusion. 

In regard to pabulum, the authors state that the more com- 
plicated the molecular structure of the culture-liquid becomes 
the more complex the forms of the mould. Cultures do not 
always behave in the same way under the same conditions. 
The reaction is of most importance to us as physicians; slight 
acidity has no influence upon the growth of the mould ; when 
the dose is sufficiently great to put obstacles in the way of 
growth, the filamentous form is produced. Moderate alka- 
linity tends to keep up the yeast form ; great alkalinity has 
toxic properties. The authors point out that alkaline treat- 
ment is beneficial in three directions; it is possible to destroy 
the fungus with alkalies; the yeast form, produced in an alka- 
line reaction, is much easier of removal than the filamentous, 
and, lastly, the fungus cannot thrive upon milk unless the 
milk-sugar be converted into lactose by the saliva ; alkalies will 
prevent this change from taking place, therefore no carbo- 
hydrates food will be present for the mould. 

As a final conclusion, after having examined into the value 
of a .great many articles as food for the fungus, the authors 
state that its alimentary requirements are distinctly different 
from the yeast of beer. 



STOMATITIS MYCOSA. 53 

Until all discussion ceases relative to the exact position 
of the thrush fungus, we will use the term saccharomyces, 
principally because it is a compromise term and because it 
shows positively that we do not believe in the existence of 
Oldium as the cause of this disease. 

Etiology. — There can be no doubt of the fact that the saccha- 
romyces is the prime cause of the stomato-mycosis. But, as is 
the case with so many infecting substances, it is necessary that 
the fungus be deposited upou soil which is favorable for its 
growth before a diseased condition can be produced. We will 
have to examine as the two etiological factors, first, the fun- 
gus, second, the patient upon whom the fungus grows. The 
natural history of the fungus is, briefly, as follows: It is 
found pretty widely distributed; in the human being, upon 
every mucous membrane, — the respiratory, the alimentary, the 
genito-urinary, — and, in several instances, in the parenchyma 
of the internal organs, the brain (Zenker), the lungs (Parrot, 
Birch-Hirschfeld). E. Wagner discovered the fungus growing 
into blood-vessels, and from thence the possibility of a general 
infection is a matter readily explained. In the wards of hos- 
pitals where the disease is most common the air will probably 
be found full of spores, which develop as soon as they come 
in contact with the proper soil. On account of the fact that 
most of the observations which have been recorded have been 
made as the result of hospital experience, they should be taken 
with some allowance, for the air being loaded with these germs, 
it is impossible to draw conclusions to which some objection 
could not be raised. A single observation made upon an 
infant in a private family under good sanitary surroundings 
would, therefore, be of more value than those made in wards 
where the poison is ever present. Unfortunately, however, we 

come here to an insurmountable difficulty. If the germ is 
the myooderma vini, it is ubiquitous, and we could hardly de- 
termine where it came from in the individual case, except from 
the air. All authors agree that the disease is found mosi com- 



54 DISEASES OF THE MOUTH (NON-SURGICAL). 

monly in infants during the first two or three weeks of life, 
although it may be found at any age. Several observers 
(Trousseau, Haussman) have found the fungus upon and 
within the female genitals, and Haussman ("Die Parasiten d. 
weibl. Geschlechtsorgane," Berl., 1870) lays stress upou the 
fact that infection of the newly-born takes place from the 
genitals of the mother during birth. The possibility of such 
an infection cannot be denied, but no proof of the fact has, 
as yet, been offered. Thrush of the vulva or vagina is rare 
(the large works on obstetrics and gynecology do not speak of 
it at all); but admitting that the parasite does occur without 
symptoms, the proof would have to be furnished that children 
born from such mothers are more liable to stomatitis mycosa 
than others. Since my attention has been especially called to 
a possible causal connection between the two conditions, I have 
examined pregnant women coming under my care for the last 
four years in this direction. During this time I have found 
but two cases in which thrush of the vulva could be diagnos- 
ticated, — one a diabetic patient, the other suffering from vul- 
vitis with lacerated perineum and prolapse of the posterior wall 
of the vagina. In neither of these cases did the children show 
signs of thrush, although the child of the first mother had to 
be brought up without mother's milk, and in neither instance 
were efforts made to prevent the development of the parasite 
if it had been present. Every one who has studied the sub- 
ject carefully will have come to the conclusion that thrush can 
be carried by the nipple, either of a nurse or of the feeding- 
bottle. The latter is especially the case in hospitals, when 
the nurses are not too careful as far as cleanliness is concerned. 
For a short time I was officially connected with a foundling 
hospital, principally for the purpose of helping in an attempt 
to reduce the fearful mortality which existed in the institution. 
I had the infants taken to a different building ; unfortunately, 
I had no control over the nurses, so that I found myself 
thwarted and gave up in despair. Of some twenty infants 



STOMATITIS MYCOSA. 55 

brought in, every one had thrush ; as far as I could discover, 
only one of the patients survived after having been removed 
from my care. The nurses prepared a large quantity of food, 
filled three or four feeding-bottles of the patented variety, and 
these were passed from one child to another. The bottles were 
never emptied, nor, as far as I could find out, ever cleaned. 
If we were to judge of the nature of stomato-mycosis from 
this experience, what an unsatisfactory condition we should 
find ! yet this has been done, especially by the older French 
writers, and even to-day the same thing is being done. 

I have seen several instances in which apparently perfectly 
healthy infants have been affected with thrush. Epstein (Prag. 
Med. Wochenschrift, 1880) mentions the case of a woman who 
nursed two children, one of whom had thrush and the other 
one did not get it. I have met with the same experience, but 
one which renders conclusions difficult to be drawn. A woman 
presents herself with her infant, apparently healthy in every 
respect (details are unnecessary) except that the child has 
thrush. In the same ward there is an infant with cholera 
infantum, — bottle-fed, marantic; in order to save this child's 
life the mother of the infant with thrush is utilized as nurse; 
the child recovers without thrush. Here is a case in which a 
healthy child has thrush and a sick child who is exposed to 
infection does not get it. As far as general good health is 
concerned, it must be admitted, then, that when it has an effect 
upon the production of thrush it must be an indirect one. 
That such is the case must be admitted upon close examina- 
tion; the indirect effect is produced by some change in the 
mouth by means of which a proper soil is formed for the 
fungus. In what docs this change consist? A great many 
theories have been advanced in solution of this fact, which 
has been known for a long time. 

It has been slated (hat for the development of thrush flat 
or Bquamous epithelium is necessary. At present there are 

so many cases on record in which the Baccharomyces alhi- 



56 DISEASES OF THE MOUTH (NOX-SL t RGICAL). 

cans has been found in places containing no flat epithelium 
(stomach, small intestines, lungs, brain, blood-vessels, etc.) 
that this cannot be admitted as an etiological factor. Where 
Grawitz has found the yeast-form cell only in the stomach, 
Parrot (" L'Athrepsie," p. 224) claims that both mycelium 
and spores are found superficially, which his plates do not 
show. This latter fact, however, is not important in this con- 
nection, as we wish to show only that flat epithelium plays a 
very secondary role in the production of thrush. There can 
be no doubt but that it is observed most frequently in the 
mouth and the pharynx, but this does not mean that it does 
not exist in other places. 

The only etiological factor which is admitted on all hands 
is the existence of a stomatitis catarrhal is, either before or with 
the appearance of thrush. A child suffering from any form 
of stomatitis (as has been mentioned in connection with stoma- 
titis aphthosa) is more liable to thrush than one without such 
an affection. Whether the catarrhal stomatitis is essential to 
the production of thrush, or whether another element is to be 
taken into consideration, is difficult of decision. Rajewsky has 
proven that an irritation of a mucous membrane is necessary 
before it can be made diphtheritic. Is it the irritation or 
the disturbance of continuity of the epithelial covering which 
makes the mucous membrane pervious to the poison ? In a 
case of thrush, is it the mechanical dislocation of the swollen 
epithelium, the separation of the cells, — all concomitant with 
stomatitis catarrhalis, — that predisposes such a membrane to 
thrush ? There are some facts that point in this direction. 
Every one who has studied the subject admits that spores of 
the saccharomyces are found in the mouths of perfectly-healthy 
children : in cultures made for me they were found four times 
out of twenty-two. They do not seem to develop under these 
circumstances; they do not obtain a foothold; they are, in all 
probability, prevented from developing by the movements 
within the mouth, especially in older children. Given a case, 



STOMATITIS MYCOSA. 57 

however, in which the mouth, especially of the young infant, 
is slightly bruised or its epithelial coating injured from at- 
tempts at nursing from badly-formed nipples, from a hard 
nipple of a feeding-bottle, with a cleft palate or what not, 
and thrush follows very rapidly. It will be seen from this 
that the feeding-bottle may be deleterious in more than one 
direction as far as thrush is concerned. These facts, taken in 
connection with some observations in the pathological anatomy 
of thrush, would make it seem that the results of a catarrhal 
trouble are to be feared more than the catarrhal stomatitis 
itself; in other words, that a mechanical condition must be 
produced which is favorable to the development of the para- 
site and which can exist either with or without stomatitis 
catarrhal is. It is impossible to conceive of an erythema or 
inflammation of the mouth which does not produce conditions 
favorable to stomato-mycosis, and all modern observers admit 
the intimate connection between these two conditions. Re- 
sulting from this comes the statement that all those conditions 
which produce stomatitis catarrhalis will favor the develop- 
ment of stomatitis mycosa. 

It is a self-evident proposition that when the parasite is 
where circumstances are most favorable it will grow best. 
For this there is necessary an amount of comparative rest 
which can only be obtained under certain conditions. From 
the pathological anatomy it will be seen that it grows in places 
where it is least disturbed. From the knowledge obtained 
through clinical evidence we know that it grows best in those 
subjects who subject their tongues or their mouths to least 
motion. We find it, therefore, principally in infants, or in 
children sick with other diseases; in adults, in all forms of 
wasting disease or in acute disease accompanied with great de- 
bility, — all of which presuppose a condition in which the func- 
tion of motion of the upper part of tin! alimentary trad is 
greatly diminished, 



58 DISEASES OF THE MOUTH (NON-SURGICAL). 

Pathological anatomy. — The parasite is taken up between 
the epithelial cells, so that at first the surface of the mucous 
membrane is comparatively free from any eruption. As a rule, 
the first development takes place so as to separate one layer of 
epithelial cells from the other ; this development is in the form 
of spores without mycelium. From this original implantation 
the parasite grows in both directions, — towards the surface of 
the mucous membrane as well as towards the connective tissue. 
In either direction do we find mycelium being developed, — to 
a very limited extent in the direction of the free surface, but 
thoroughly well in the direction of the connective tissue. Once 
the basement mucous membrane has been perforated, and the 
character of the growth seems to change so as to produce those 
pictures which have been put down in the books as the classi- 
cal appearance of the parasite. From this method of develop- 
ment it will be seen why a squamous epithelial coating will 
favor the growth of saccharomyces albicans, and why, on the 
other hand, mucous membrane lined by cylindrical epithelium 
is not favorable to its growth. 

In the mucous membrane with flat epithelial cells, the para- 
site can develop between the individual layers of cells ; in the 
mucous membrane with cylindrical epithelium, there are no 
layers between which the spores can develop. When they fill 
up the follicles then the growth goes on, — it is the surface 
growth that we are referring to, — but especially well into the 
submucosa and the nervea. Very much has been said about 
the exact relation which is borne by the parasitic growth to the 
outer epithelial layer of the mucous membrane. A careful in- 
vestigation of each case will show that the beginning of each 
growth is usually as has been described ; that the saccharomyces 
then develops so as to implicate all the various layers of the 
epithelium. In attacking the most external layer it develops 
between the cells, raises them up, surrounds them, embeds them 
within its rapidly-increasing growth, so that, finally, it is im- 



STOMATITIS MYCOSA. 59 

possible to distinguish epithelium from parasite unless the 
microscope is used. These facts are of great importance from 
a therapeutic stand-point. The implication of blood-vessels, 
which Wagner affirms and which Parrot denies, is a question 
which does not interest us for the present. But the affection 
of surrounding tissue as a result of the presence of the para- 
site is of some importance. The vegetable produces all the 
signs of irritative change, — proliferation of the cells, especially 
their nuclei, but no pus. The evidences of irritation are of 
the most transitory nature and vanish very quickly when the 
parasite is removed. The question whether or no pus is formed 
is at the present day of no importance whatsoever. It must 
be taken for granted that the saccharomyces albicans does not 
belong to that class of parasites called the pus-formers, as the 
formation of pus must be looked upon as the exception and 
not the rule. The extension of the parasitic growth to other 
parts of the body has already been referred to and will receive 
discussion in connection with the symptomatology. 

On account of the nature of its inception, the growth begins 
in the form of small spots, which may or may not become con- 
fluent. It may then be propagated either from this first crop 
or, what is more likely, in mild cases, two or more places may 
become inoculated from the same source. In microscopic prep- 
arations we sometimes see one islet connected with the other by 
threads of mycelium in the connective tissue. In violent cases 
a deposit of a mass occurs, leaving very little healthy tissue. 

Symptomatology, — It has been admitted thatachild, perfectly 
healthy in all respects, can be infected with thrush, and the 
attempt has been made to show that the first lodgement of the 
parasite is due more to mechanical causes than to any other 
circumstance. Yet the former proposition must be accepted 
a- the exception and not the rule, and the latter as signifying 
that children whose mouths are otherwise affected are, as a rule, 
more liable to these mechanical conditions than healthy ones. 



60 DISEASES OF THE MOUTH (NON-SUKGICAL). 

It will follow, therefore, that the symptoms of stomatitis mvcosa 
are of a complex nature; those due to the stomatitis and those 
due to remote conditions, either predisposing, coexisting, or 
following the lesion of the mouth. 

It will be seen that the term stomatitis mycosa has been 
used to designate the affection under discussion. This has 
been done because, in every instance, there are present the 
evidences of a stomatitis which is due to the irritation produced 
by the fungus; therefore a stomatitis mvcosa. The subjective 
symptoms produced by the fungus, in a purely local case of 
thrush, vary with the intensity of the affection. In some 
cases, when the affection is but slightly developed, the patient 
suffers very little, if at all. It can be put down as a rule that 
pain is present only when the corium is attacked. The me- 
chanical disturbances produced may be varied and various, 
depending entirely upon the part of the mouth affected. In 
the beginning we usually see the tip of the tongue the seat of 
the trouble. With this the lips are affected, and from these 
two places the parasite may grow in all directions. Most 
commonly, the tongue suffers most; from it infection may 
take place upon the tonsils, and then we have the symptoms 
of an amygdalitis, difficulty in swallowing, painful swallowing, 
and, finally, absolute refusal of food. When the tongue and 
the lips alone are affected, provided always the fungus has 
grown into the corium, we get the symptoms described under 
catarrhal stomatitis. In those cases in which the saccharomy- 
ces has grown upon the oesophagus the symptoms may become 
still more intense. Cases are on record in which the whole 
of the oesophagus has been filled up with a cylindrical cast 
made up entirely of the spores and mycelium of the parasite. 
There is no doubt that the observations of the French authors 
(Valleix, Seux) are correct as to the frequency of thrush in 
the (esophagus. These observers found it in thirty-two cases 
out of forty-two which were examined post-mortem. Although 



STOMATITIS MYCOSA. 61 

this ratio overestimates the comparative frequency of thrush 
of the oesophagus, yet we have no positive proof that it does 
not exist during life. It is certain that autopsies, carefully 
conducted, will show the presence of thrush in the oesophagus 
in a far greater number of cases than we have reason to sup- 
pose when judging from the symptoms alone. When a plug 
is filling out the oesophagus, swallowing becomes impossible; 
but, fortunately, the attempt is sometimes followed by vom- 
iting, by means of which the plug may be expelled. The 
question whether the saccharomyces produces gastro-intestinal 
troubles has been answered in various ways. The French 
authors claim that it does, and, in addition, that intestinal 
troubles are almost a conditio sine qud non of stomatitis 
mycosa. On the other hand, Bohn and most of the German 
authors claim that the disturbances of the intestinal tract 
frequently precede the stomatitis, and can, therefore, not be 
looked upon as sequela?. It has already been pointed out 
that intestinal troubles need not accompany, precede, or follow 
thrush, and it has been slated that hospital patients are not the 
class of subjects upon which observations of this nature should 
be made. Especially is this the case when the hospitals in 
which these studies were made are themselves taken into 
consideration. If the experience of private practice be con- 
sidered, it will be seen that bowel troubles with stomatitis 
mycosa are the exception and not the rule. This is especially 
applicable to that better class of patients that watches its 
children intelligently. For when thrush is treated properly 
in its beginning, intestinal or gastric troubles are simply out 
of the question. ( )n the other hand, disturbances of the gastro- 
intestinal tract are the rule when stomatitis mycosa is under 
full headway. It is probable that the saccharomyces is alone 
Bufficienl to accounl for attacks of dyspepsia when swallowed 

in greal quantity; bul it is certain thai the (akin-- into the 
stomach of greal quantities of saliva, holding in solution the 



62 DISEASES OF THE MOUTH (xOX-STJRGICAL). 

chemical results of the biological activity of the fungus, fre- 
quently causes catarrhal troubles of the gastro-intestinal mucous 
membrane. When the fungus develops in the mucous mem- 
brane it produces the symptoms of well-marked disturbance. 
Statistics are wanting concerning the frequency of all these 
occurrences. But it will be seen that thrush as a slight 
localized affection and under proper conditions need not affect 
the patient very seriously, while an extension to the tonsils, 
the oesophagus, the stomach, or even an extensive localized 
invasion of the mouth, must always be looked upon as a serious 
matter because of the digestive troubles which may follow. 
Again, thrush, when developing in a debilitated patient, the 
debility due to any cause immaterial, whether from gastro- 
intestinal disturbances, typhoid fever, pneumonia, phthisis, or 
what not, becomes a very much more serious disease than in 
a healthy child. Thrush occurs in debilitated subjects, as has 
been pointed out, and the most common cause for debility in 
infants is disease of the mucous membrane of the gastro- 
intestinal tract; it was therefore quite natural that the two 
conditions should have been looked upon as bearing the relation 
of cause and effect to each other. The fact remains that the 
former simply bears the relation of predisposing cause to the 
latter, the saccharomyces being the real cause. 

Formerly great stress was laid upon the appearance of 
intertrigo with thrush, and it cannot be denied that intertrigo, 
or eczema ad natem, does occur very frequently in patients with 
stomatitis mycosa. The explanation is to be found in the 
fact that infants who have disturbances of the gastro-intestinal 
tract frequently have intertrigo ; but this is due not to the sac- 
charomyces but to the chemically-altered stool which irritates 
the skin over which it passes. 

AVe find the characteristic lesions of thrush in the mouth. 
The. beginning, as has been stated, is most commonly at the 
tip of the tongue, and we here see small, discrete, grayish- white 



STOMATITIS MYCOSA. 63 

spots. "When these are carefully examined by reflected light, 
it will be observed that they are covered by epithelium and 
are surrounded by a narrow ring of injected blood-vessels. 
Upon attempting to remove them it will be found that con- 
siderable violence is required, and when it is accomplished 
there is left a red surface, slightly depressed, which bleeds 
very readily. The latter condition obtains for all the various 
stages of the eruption, unless the whole mucous membrane is 
very much swollen, when a slight depression cannot be noticed. 
In the next period of development the spots will have grown, 
not so much in diameter as in height, and it will then be seen 
that they project somewhat beyond the level of the mucous 
membrane. This occurs in a comparatively short time, and 
after it more or less general infection of the mouth takes place. 
The latter does not follow as a necessity, but if these first two 
states go on unnoticed, the chances are very much in favor of 
more or less general infection. After this the spots enlarge, 
sometimes meet, and then the whole tongue may look as if 
covered by a membrane, the color of which depends upon the 
color of the food. When not colored by the food the mem- 
brane looks a dirty grayish white. 

Sometimes the eruption begins upon the lips, the cheeks, or 
the soft palate; as a rule, that part lying directly opposite to 
the place first infected becomes affected next. When thrush 
begins upon the tip of the tongue it is the mucous membrane 
of the lower lip which becomes affected; when upon the cheek 
it is that part of the tongue which rests against the infected 
cheek, so that a direct connection between the primary and 
secondary invasions can be traced out. Again, under such 
conditions, it will be found that the two eruptions are in dif- 
ferent states. The difference does not exist where cases are 
very far advanced and the various spots look alike. The 
mucous membrane between the spots is usually very much 
injected, of a dark-red color, and showing evidences of catarrhal 



G4 DISEASES OF THE MOUTH (XON-SURGICAL). 

stomatitis. At times the fungus drops off or is detached, and 
slight ulcerations remain which may again be filled up with 
the parasitic mass in a very short time, or may remain as 
ulcerations, rather intractable, and of a very chronic nature 
if left to themselves. These ulcers may be the source of in- 
fection from poisons of a different nature, and ought, therefore, 
to demand the attention of the physician. 

The differential diagnosis has been left for consideration 
until the various forms of stomatitis shall have been discussed. 
There is one point to which especial attention must be called 
in this connection. The beginner is sometimes at a loss to 
decide whether he is dealing with small masses of coagulated 
milk which have remained upon the mucous membrane or 
with thrush. If a camel's-hair brush or the finger be applied 
to coagula, it will be seen that they can be removed without 
any difficulty; with thrush, difficulty will be experienced and 
there will be left the raw surface. When the appearances are 
studied with care it rarely becomes necessary to use the micro- 
scope for making the diagnosis positive. But where there is 
any doubt, the microscopical appearance of the saccharomyces 
will be found so positively clear that there can be no hesitancy 
in their recognition by the veriest tyro. 

Prognosis depends more upon the patient in whom thrush 
develops than upon the thrush itself. A local process in an 
otherwise healthy child is perfectly harmless, especially when 
properly treated. Thrush in a debilitated, enfeebled infant 
may be the cause of death, — the straw that breaks the camel's 
back. Again, stomatitis in a child with bad hereditary ten- 
dencies may become a very serious affection. Furthermore, 
the place of development must be taken into consideration. 
A serious invasion of thrush in the oesophagus will almost 
always be fatal; one may not be able to diagnosticate its ex- 
istence, and even when this is done its removal is next to 
impossible. The younger the child, the more extensive the 
eruption, the worse the prognosis. 



STOMATITIS MYCOSA. 65 

Last comes the factor of treatment. Careful management 
will do most to lessen the mortality from stomatitis mycosa. 
This should be especially taken into consideration by hospital 
physicians. There is no possible excuse for the high mortality 
reported from thrush ; with the light thrown upon the subject 
from the laws of disinfection, cases can certainly be isolated 
without difficulty, so that the weak in the wards can be pro- 
tected. In private practice it is a matter of extreme rarity to 
see a patient die from stomatitis mycosa, although all cases 
should be carefully treated, as many complications can be pre- 
vented which, although not directly fatal, may finally influence 
the child's condition of health. 

Treatment. — Prophylaxis is of as much importance in this 
affection as the treatment proper; but cleanliness is absolutely 
imperative in both. As to prophylaxis, it is necessary to 
remember that all slight abrasions of the mucous membrane 
may become infected with the saccharomyces albicans. Further- 
more, everything must be watched which might, by any possi- 
bility, be a place for the development of the fungus in appreci- 
able quantity. For this reason it is well to teach the mother 
or the nurse how to keep the nipples clean, and how to cleanse 
the mouth of the infant. Wet-nurses should always be care- 
fully inspected, their nipples and the mouths of their children 
inspected before permission is given to nurse the child for 
whom they are engaged. "When the child is brought up on 
artificial food, the whole apparatus for feeding must be kept 
scrupulously clean, and the attendants must be taught how to 
do this. Not only is this important as far as thrush is con- 
cerned, but also in a great many other directions. The best 
and, upon the whole, the safest disinfectant for the feeding 
utensils is exposure to the temperature of boiling water for 
:i Utile while. Bui every pari of the apparatus should be so 
arranged lhal boiling water can <_ r ain access to it, and that 
any deposit can be removed mechanically, When this is 



QG DISEASES OF THE MOUTH (NON-SURGICAL). 

rigidly carried out, infection becomes impossible even in hos- 
pitals. 

When the diagnosis has been made the treatment proper 
will consist of two distinct parts: the first, the mechanical 
removal of the fungus; the second, its destruction. A mod- 
erate amount of violence is necessary to accomplish the first, 
and, in order to insure the carrying out of instructions, it is 
best to reduce instructions to a method. The attendants must 
be told to wash out the mouth at stated times, — for instance, 
between the times of nursing and immediately after nursing. 
It has been found that removal of the growth is easier when 
an alkali is used ; for this purpose the sodium bicarbonate (one 
dram to a tumbler of water) is very serviceable. Whether or 
no it has antimycotic effects, as far as the saccharomyces is con- 
cerned, is debatable ground. In former days the assumption 
that the fungus could not exist upon an alkaline soil was taken 
for granted, and because the saccharomyces was followed by an 
acid reaction, therefore an alkaline remedy was the proper one. 
Even if the soda has no especial effect upon the parasite, it 
has its indications in thrush, not the least important being 
that it causes the epithelial covering to be removed more 
readily, so that we can get at the fungus; where the epithelial 
coating has already been removed, it causes the mycelium to 
be less adherent, solving mucus and the substance holding the 
threads together. In addition, the remedies to be used must be 
applied frequently — four or five times daily — and with a brush. 

In using remedies for thrush, it has been my custom for 
years to avoid prescribing syrups; the orthodox borax and 
honey mixture has always seemed to me to add fuel to the fire. 
Any number of medicines have been recommended in the 
treatment of this affection : potassium chlorate, pota>siuin per- 
manganate, borax, boric acid, the hyposulphites, salol, etc. 
This fact alone shows that they are of secondary importance, 
for all have supporters, and all have been followed by good 



STOMATITIS MYCOSA. G7 

results. If the physician but adheres to the mechanical re- 
moval of the fungus masses, cure will follow. Up to the 
present the remedy or remedies which will prevent the growth 
of the saccharomyces albicans has not been experimentally 
determined upon. As far as my own experience is concerned, 
I have rarely found it necessary to use anything but sodium 
bicarbonate. Occasionally, when ulcers are produced, it be- 
comes necessary to touch them with silver nitrate, but in 
uncomplicated cases this is exceedingly rare. There are some 
cases which will resist any method or all methods of treatment. 
But no case, when taken in the beginning, should be allowed to 
6pread; a careful examination of the mouth will reveal the 
points of development of the fungus, and their removal ends 
the disease as far as those places are concerned. 

Calomel in small doses or corrosive sublimate very much 
diluted almost always act as specifics in intestinal troubles 
which are due to thrush. But the relation between intestinal 
troubles and thrush must always be kept in mind, and the 
indiscriminate use of cathartic alkalies or other laxatives must 
be prevented as doing the patient more harm than good, re- 
ducing his strength and being absolutely harmful and needless. 
Baginsky claims good results from resorcin, and warns against 
tin- useof too large a dose (from one-half to one-per-cent. solu- 
tion — never more than one teaspoonful every two hours). It 
i.> difficult to conceive how this, or any other remedy, is going 
to produce an effect upon an oesophagus stopped up completely 
by plugs of parasitic growth. When a conjectural diagnosis 
of oesophageal thrush has been made, it seems most expedient 
to introduce tin: soft catheter into the oesophagus. In one 
case I have succeeded in gradually working my way into the 
Stomach with a catheter; some of the masses were pushed into 
the stomach and were then removed by vomiting. The patient, 
however, died a lew days afterwards, and post-mortem exami- 
nation showed the oesophagus again filled up. 



68 DISEASES OF THE MOUTH (^OX-SURGICAL,). 



IV. 

STOMATITIS ULCEROSA. 

Synonym.es. — French, Stomatite Ulcero-memhraneuso ; German, Stom- 
acace, Mundfaule. 

We have to deal here with a disease with a very limited 
literature, with a most distinctive clinical picture, and one 
whose causation is as yet unknown, except as a matter of the- 
ory. To this might be added, a disease whose treatment is 
thoroughly well understood. 

The historical development is that of comparatively recent, 
times. We find the French authors first describing the affec- 
tion either as a gangrenous process (Taupin, 1839), diphtheria 
of the mouth (Bretonneau, Trousseau), and, finally, as an ul- 
cerative-membranous process (Barthez and Rilliet, and those 
following). In England, West was one of the first to publish 
an excellent description of the disease, and then to give us the 
remedv, which is almost a specific. In Germany, Avriters like 
Jorg, Wendt, Schnitzer, and Wolf (1826-1844) give descrip- 
tions of stomacace, which, however, are not always per- 
fectly clear as far as our present knowledge goes, so that the 
credit of the first sharply-cut description belongs to Bolm 
(186G). From this time little, if anything, has been added to 
our knowledge upon the subject; all the hand-books contain 
more or less lengthy chapters upon this disease, with descrip- 
tions more or less accurate. The position of the disease in 
nosology, then, is well recognized, and all modern writers, not- 
withstanding omissions in description, seem to have seen the 
same thing when they write about ulcerative stomatitis. The 
various views that have been held concerning the nature of the 
disease can be omitted as subjects of historical importance, but 
as valueless at the present day. 



STOMATITIS ULCEROSA. 69 

Stomatitis ulcerosa is a disease characterized by a peculiar 
pathological process, which terminates iu molecular destruction 
of tissue. It begins on the gums around the teeth, it never 
extends beyond the cavity of the mouth, and it has the power 
of inoculating other parts of the mucous membrane. It may 
be well to emphasize the fact that stomatitis ulcerosa does not 
occur where there are no teeth. 

Etiology. — Much has been written concerning the cause or 
causes of this disease, but as yet we only have clinical evidence, 
which shows that in the majority of cases there are two factors 
at work, — the one general, the other local. It has been con- 
ceded by all authors that there are certain poisons which will 
produce a clinical picture identical with that of stomatitis ul- 
cerosa. First and foremost comes mercury, then lead, phos- 
phorus, and copper, to which might be added iodine. In these 
days, when we have almost returned to the mercury-therapy of 
our forefathers, it is well to remember that mercury will pro- 
duce stomatitis, and much more rapidly in children than in 
adults. Indeed, fifteen or twenty years ago mercury was used 
with the greatest care in children, because of the knowledge of 
this fact, which seems to have been forgotten in our enthusiasm 
tor antiseptic remedies; and not a little of the success of some 
physicians with medical idiosyncrasies was due to their not 
using mercury. 

If we admit the mercurial stomatitis a.s typical of and iden- 
tical with the stomatitis ulcerosa, it is possible to arrive at 
some conclusion regarding the nature of the affection. Mer- 
cury is partially excreted by the saliva, and accompanying this 
process there is more or less inflammation of the mouth. It is 
a notorious fact that where there already exists an irritation of 
the mucous membrane, in the form of a carious tooth, or the 
hyperemia of alcoholics or of smokers, there the inflammation 
will take place with most intensity, and is frequently followed 
by the production of ulcers. If we examine into the process 



70 DISEASES OF THE MOUTH (nOX-SUEGICAL). 

as it is going on here, Ave are forced to the conclusion that we 
are dealing with a process purely local in its nature. This is 
quite true, for in many instances a mercurial stomatitis is pro- 
duced long before systemic reaction has taken place, on account 
of prolonged administration of mercury. Yet the local effect 
upon the mouth comes from the general system, and the mer- 
cury is to be looked upon as predisposing cause as much as the 
immediate cause. In other words, to produce a stomatitis ul- 
cerosa it is necessary that the mucous membrane be prepared in 
some way, so that the process itself can be continued. Before, 
we have stated that the mercury acts both as predisposing and 
immediate cause. The latter cannot be verified, except in that 
mercury will, in most instances, produce stomatitis ulcerosa 
when pushed far enough. 

Naturally, the question of the role that is played by lower 
organisms would come up here as well as in every inflam- 
mation. In the investigations that I have made, the result 
was positive only in so far that the various pus-producers 
were found, which could have been expected. The as- 
sumption that the mercury causes the mucous membrane 
to be changed in such a way as to become a good soil for 
the development of these pus-producers could not be main- 
tained. For it is not an ordinary pus-producing process that 
we are dealing with, as will be seen from the pathological 
anatomy, but one that is almost unique in its way. That 
there is some specific cause at work must be taken for 
granted, on account of the peculiar nature of the process, 
and that this cause is in the nature of a lower form of life, 
or some infectious agent, is proven by therapeutic measures. 
We know that stomatitis mercurialis can be almost indefi- 
nitely prevented by absolute cleanliness. We know, further- 
more, that certain agents, having for their physiological effect 
the giving off of oxygen, will relieve and cure stomatitis ul- 
cerosa most rapidly. We are, then, forced to the conclusion 



STOMATITIS L'LCEROSA. 71 

that in stomatitis mercurial is, or ulcerosa, there is, first, a 
general cause (better systemic) and a local cause. The local 
cause in stomatitis mercurial is cannot be definitely ascer- 
tained, but reduces itself either to mechanical irritation pro- 
duced by excreted mercury (lead, phosphorus, iodine, etc.) or 
some infectious agent. 

If we now apply this knowledge to stomatitis ulcerosa in 
subjects not under the physiological manifestations of these 
remedies, it will be seen that clinical facts will give us data 
more or less satisfactory. As to general causes, Barthez and 
Rilliet say, " II n'est pas une des maladies de l'enfance dans 
le cours desquelles elle ne puisse survenir" ("There is not a 
single disease of infancy during the course of which it could 
not develop." Barthez and Rilliet, vol. i. p. 201). With us 
there are certain diseases which are accompanied by this form 
of trouble more frequently than others, — the eruptive dis- 
especially measles and scarlatina, malarial troubles, 
typhoid fever, pneumonia, and whooping-cough. Children 
affected with rachitis, syphilis, or tuberculosis are apt to have 
this trouble. Again, on the other hand, there are those chil- 
dren who seem to be comparatively healthy, in whom the 
least disturbance will bring on an attack of stomatitis ul- 
cerosa. Cases will come under observation in which there 
will be repeated attacks of this disease, provoked by a bron- 
chitis, a slight gastric disturbance, au attack of coryza. I 
have under my charge a child, now five years of age, who, 
since the appearance of his teeth, has had stomatitis ulcerosa 
follow almost every illness he has had, whether slight or severe. 
Except for a slight enlargement of the glands in the neck this 
child seems to be 1 perfectly healthy. 

Nearly all writers have laid stress upon the external sur- 
roundings of the patient as cause. Barthez and Rilliet (/oc. 
eft.) state t li.it tin; disease is endemic in some wards of some 
hospitals. Nearly all authors (Taupin, Bohn, Henoch) claim 



72 DISEASES OF THE MOUTH (xOX-SURGICAL). 

an effect from clamp, poorly-ventilated houses. Unsalubrious 
climate is also accused of causing this disease,— i.e., rapid 
changes from warm to cold, from dry to moist, etc. The diet 
of a child must also be looked upon as causative. A poorlv, 
badly-nourished child will be more apt to have the affection 
than one correctly fed, so that poor children are more liable 
to the disease than the children of well-to-do parents. Scor- 
butus lias also been put down as one of the general diseases 
producing stomatitis ulcerosa. This disease is so very rare in 
children in this country that practically the relation is unim- 
portant. 

For local causes in the mouth we must look to the teeth 
principally. Bohn says, " Without teeth no ulcerative stoma- 
titis." The explanation for this fact is to be found, probably, 
in that the gums form a favorable place for the poison to de- 
velop. That disease of adults known as dental pyorrhoea — 
shrinking of the gums— is frequently produced by the accumu- 
lation of tartar at the bottom of the teeth. Sometimes this 
form of trouble is nothing more or less than a true stomatitis 
ulcerosa, even in the adult. Now, while it is extremely rare 
for children to have tartar upon their teeth, — i.e., during the 
period of first, or the beginning of second, dentition, — the pro- 
duction of this deposit shows how easily substances may accu- 
mulate upon the teeth around the gums. When we take into 
consideration that adults sometimes, even with the greatest care 
and cleanliness, cannot prevent this deposit of tartar, it seems 
very rational to believe that children whose mouths are apt to 
be imperfectly cleaned, if at all, may have substances deposited 
upon their teeth. Now, given a child which has its gums pre- 
pared by some general trouble for the reception and growth of 
the poison or irritant of stomatitis ulcerosa, and the origin of 
the trouble is readily understood. Where the irritation is ab- 
normally great, as from bad teeth, the result of syphilis, 
rachitis, or carious teeth, it is quite clear that stomatitis ul- 



STOMATITIS ULCEROSA. 73 

cerosa will be more apt to be developed, and when developed 
more intense, than in a child with healthy teeth. 

That stomatitis occurs endemically in certain wards of a hos- 
pital, in certain barracks, or among a certain class of soldiers, 
has been known since Berjeron, Taupin, and Barthez and Ril- 
liet. By some authors the term epidemic was used instead of 
endemic, and the discussion naturally arose concerning the 
contagiousness of the affection. The older writers thought 
the affection was contagious, while most of the modern writers 
(Bohn, Henoch, Gerhardt, and others) reject this idea. Hirsch 
(Ilandbuch d. Hidor. Geograph. Path.) comes to an opposite 
conclusion, which, it will be seen, is probably the correct one. 
The argument used by all who oppose the contagious nature 
of the affection is, that all attempts at inoculation of children 
have given negative results. In the present state of our knowl- 
edge of infectious diseases it will be granted that a conclusion 
based upon facts such as have been enumerated is inadequate. 
The experiment made, was to take some of the secretion or 
pus from a surface affected with stomatitis uleerosa and in- 
oculate the gums of another child with it. The result being 
negative, the disease is not contagious. We are now fully 
convinced of the fact that it takes more than the presence 
of a virus to produce a given disease. In this connection it 
is necessary only to refer to the experimental attempts made 
to inoculate typhoid-fever germs or cholera, which have so 
often been attended by failure, and which, when done in the 
correct way, arc followed by success. So it is with stomatitis 
ulcerosa. Given a patient whose gums are in a proper condi- 
tion, and inoculate these gums with pus from a stomatitis ul- 
oerosa, and the result will bo stomatitis ulcerosa. The trouble 
in making this experiment is that we are not in a position to 
state positively that in a given case the gums are in such a 
condition as to lie affected by the virus. [f we take healthy 
children and try to inoculate their gums with this poison, the 



74 DISEASES OF THE MOUTH (XON-SURGICAL.). 

result will always be negative. In some researches which I made 
five years ago this was proven to my complete satisfaction. In 
making these experiments upon healthy subjects, I never suc- 
ceeded in producing anything more than a slight inflammation, 
which got well very readily. It must be confessed, further- 
more, that positive results which were obtained upon sick chil- 
dren were the exception and not the rule. But this was due 
to the difficulty of choosing proper subjects. The patients 
that I took, in whom I expected to get results, were affected 
either with rickets, so-called scrofula, or had very bad teeth 
with swollen gums. In all the cases in which I tried but 
three were successful. In these three cases there was present 
in one tuberculosis, and in the other two nothing more than 
carious teeth, with a very bad condition of the gums. The 
great objection which could be raised to this series of experi- 
ments is, that the patients with whom I succeeded were under 
the same hygienic influences as those that had the disease. In 
the first case, one other member of the family had the affection, 
and the other two belonged to the same family, and were in- 
oculated from material taken from a third member of the same 
family. It may be urged that all of these three patients might 
have had the disease even if they had not been inoculated. 
However, the stomatitis followed so quickly after inoculation 
began at the spot where the pus was introduced, and the patients 
had been exposed to the bad hygienic conditions for so long a 
time, that the observer could not but be impressed by the fact 
that the disease followed the introduction of the poison into the 
diseased gums. I am far from accepting these results as con- 
clusive, as I wish to extend the observation, hoping to succeed 
by inoculating pure cultures of the bacteria found in stomatitis 
ulcerosa upon proper soil. But of this much I am convinced, 
that it takes more than bad hygienic conditions, poor air, etc., 
to produce a stomatitis ulcerosa. Again, for prophylactic pur- 
poses, it is of the highest importance to remember that the 



STOMATITIS ULCEROSA. 75 

possibility exists of having the disease transmitted from one 
member of the family to another. It is not an uncommon 
observation to have more than one member of the same family 
affected by this disease. I have seen all the children in a single 
family — seven in one instance — in various stages of stomatitis 
ulcerosa. When we see how, for instance, for the causation 
of alopecia areata, Lassar (TJierajieut. Monatshefie, ii., 1888) 
shows that the use of the same hair-brush, or going to the same 
barber, can be accepted as evidence of the infectious nature of 
that affection, we are certainly justified in using the frequent 
occurrence of stomatitis ulcerosa in different members of the 
same family as an argument in favor of its being infectious. 
For stomatitis ulcerosa we have even more direct contact than 
is proven for alopecia areata, — kissing, using the same table 
utensils, etc. 

That the soldiers alone, and not the officers, become affected 
with this disease, when it becomes epidemic in garrisons, has 
been used as an argument against the non-infectious nature of 
stomatitis ulcerosa. It is claimed that the soldiers are under 
worse hygienic effects than the officers. That they come into 
more intimate contact with each other; that they wash out of 
the same basin, use the same drinking-cups, sleep together in 
large rooms, etc., is lost sight of altogether by those who insist 
upon the disease not being infectious. The officers, on the 
other hand, do not live together as do the soldiers, and, there- 
fore, cannot infect each other as the soldiers do. Again, the 
rarity of the disease among seamen has been alluded to by 
Berjeron, and has been ascribed to the fact that the air upon 
the ocean i-^ better than upon the land, therefore soldiers have? 
the disease more frequently than sailors. The explanation for 
the comparative rarity among seamen is not the proper one, 
!>ut the fact that all governments have been careful to regulate 
and train their Bailors in such a way that they may escape that 

much-dreaded disease of the sea, scurvy. In doing this, espe- 



76 DISEASES OF THE MOUTH (NON-SUBGICAL). 

cial attention is called to the condition of the mouth, and when 
any disease occurs there it is immediately looked to. Further- 
more, all those means employed to combat scurvy — good nutri- 
tion, good air, cleanliness of the mouth — are excellent means 
to prevent the development of favorable soil for stomatitis ul- 
cerosa. Unfortunately, for a conclusive decision of this mat- 
ter, experiments are still wanting as to the exact nature of the 
poison and the nature of the soil. 

The disease occurs principally between the ages of five to ten 
years; it is rare after this time, and very rare before the age 
of four to five years. 

Pathological anatomy. — Bonn was the first to call attention 
to the fact that in this disease we are dealing with a process 
which A T irchow calls necrobiosis. It is not necrosis, because, as 
Virchow states, the conception of the necrotic process implies 
more or less retention of the external form of the organ or tis- 
sue involved. In the necrobiotic process we have to deal with a 
process which usually ends in softening, and in which there is 
molecular or cellular necrosis, so that the tissue becomes more 
fluid in its consistency and more movable. (See Virchow, " Cel- 
lular Pathologie," p. 402, 18 71.) If we examine the products 
of stomatitis under the microscope, we find very few evidences 
of the cells of the invaded tissues, but a molecular detritus 
mixed with lower forms of life, and here and there pus-cells. 
The process does not respect any part of the mucous mem- 
brane upon which it may be located, so that, while it begins 
upon the surface, the deeper structures of the gums, including 
the periosteum, are not infrequently invaded. When the pro- 
cess is most intensely developed, necrosis of bone is the result. 
I have in my possession the alveolar process of the lower jaw 
containing the four incisors which had to be taken away from 
a child affected with stomatitis ulcerosa. At times the pro- 
cess produces a complete loosening of the teeth, and when 
these are extracted the disease becomes tractable. At other 



STOMATITIS ULCEROSA. 77 

times the periosteum is more extensively affected, and small 
sequestra are separated ; again, the pathological change is so 
extensive as to involve one whole division of the bone. In 
all the specimens, however, that I have been able to examine, 
there was no caries of the bone ; as if the stomatitis had been 
unable to attack osseous tissue. The necrosis was evidently- 
due to a stripping up of the periosteum, and as the alveolar 
process is not attached to the jaw with any great amount of 
firmness, being, as Hunter expresses it, "a part of the teeth," 
its detachment without caries could be readily explained as far 
as its lower border was concerned. Laterally, however, as far as 
the researches in embryology teach us, the detachment must 
have been the result of an ulcerative process, therefore caries. 

The affection always begins upon the gums and in a specific 
locality, — at the free border. Thence it extends, as has been 
stated above, in all directions, causing the destruction pecu- 
liar to it. But the parts which lie in apposition to those 
primarily affected are apt to become infected, yet in such a 
manner that the process never extends beyond the buccal 
cavity. 

Symptomatology. — Stomatitis ulcerosa begins with swelling, 
injection, and loosening of the mucous membrane about the 
teeth. At first the swelling will be observed only at the lower 
part of each tooth, so that the outline of the gum is altered, 
but not very much. Gradually the swelling increases and the 
mucous membrane begins to cover the lower portion of the 
tooth, so that the outline, instead of being curved, becomes 
almost straight. In the beginning the gums are affected only 
in bo far as they form a covering for the teeth, leaving the 
spaces between the teeth unaltered. These spaces represent 
the hills of the natural curved outline of the gum, the mucous 
membrane covering the teeth representing the valleys. As 
the latter swell up, they come to a level with the elevations, 
producing an appearance almost pathognomonic for stomatitis 



78 DISEASES OF THE MOUTH (XOX-SURGICAL). 

ulcerosa. The swelling may be so great as to produce a slight 
eversion of the part affected, and is always accompanied by 
injection, which gives to the mucous membrane a livid appear- 
ance. The overfilling of blood is so great that, as a rule, 
bleeding takes place, frequently produced by the slightest 
movement of the jaw, or by pressure, such as is produced by 
touching the gums during the actof examination by the physi- 
cian. As a rule, the disease is confined to the anterior aspect 
of the gums, but when certain symptoms are present the care- 
ful physician will examine the posterior aspect as well. The 
rule certainly is, that the disease begins upon the anterior 
aspect ; that there are exceptions is more than probable. In 
bad cases, however, both anterior and posterior portions of the 
gum become the seat of the disease. Very soon, accompanying 
the eversion, the gums are detached from the teeth, and some- 
times before the process develops further they can be pulled 
away from the teeth with very little force, leaving exposed a 
cavity, which is filled with a peculiar muco-purulent secretion. 

Even at this stage the yellowish seam at the top of the 
swollen outline of the gum may be perceptible. This is due 
to the molecular destruction which has already begun, and its 
presence makes diagnosis easy. The yellowish seam is at first 
very narrow; it may grow to abroad band, involving almost 
the whole of the gum. 

Accompanying these symptoms the patient has a great deal 
of saliva pouring from his mouth. There is no disease in 
which salivation is so great as in stomatitis ulcerosa, and, in 
my experience, it is the most constant symptom. It also gives 
us an index to the completeness of our cure, and no case 
should be discharged until the moisture in the mouth is nor- 
mal. Another symptom is the fetid odor of the breath and of 
the mouth ; this arises directly from the diseased surface, not 
from the saliva. When the latter is collected, and great quan- 
tities can be easily obtained, it will be found, in the majority 



STOMATITIS ULCEROSA. 79 

of cases, to be odorless. Only in very bad cases, such as will 
be described, does the saliva also have a penetrating fetid odor. 
Curiously enough, this disease produces few general symptoms, 
and, especially in older children, little is complained of by the 
patient. Frequently the patient is brought to the physician on 
account of the fetid odor or on account of the salivation. In 
very young children the subjective signs are usually better pro- 
nounced. The child becomes fretful, cries a great deal, refuses to 
eat, has slight elevation of temperature, sleeps badly, and very 
soon begins to lose flesh. I have seen symptoms produced in this 
class of patients which would lead to the assumption of a much 
more serious affection. In several cases the whole disposition 
of the child seemed changed ; instead of a good-natured, healthy, 
and contented baby, there was a fretful child, crying all the 
time, and a look of distress and fatigue on its face which seemed 
to bode evil developments. One patient cried for days from 
pain, almost incessantly through the twenty-four hours, only 
dropping off to sleep from sheer fatigue. By proper treatment 
the whole clinical picture cleared up in a very short space of 
time. Parents who have once seen an attack of stomatitis 
ulcerosa are quick to recognize a repetition, and, having seen 
the good effects of remedies, are just as quick to apply them. 

The lymphatic glands take part, and swell up; they are 
usually soft, and remain swollen until the process has come 
to an end. Frequently these glands continue to be enlarged 
long after the disease has run its course; rarely do they take 
active part so as to be inflamed, although the suppuration of 
the glands under the maxilla may occur. 

In the various conditions described the disease is readily 
conquered without any active interference except the adminis- 
tration of remedies. When this condition is overlooked a 
further development usually takes place. Although a suba- 
cute or chronic form must be recognized, in which these symp- 
toms last for an almost indefinite length of time, yet such 



80 DISEASES OF THE MOUTH (NON-SURGICAL). 

cases are exceptions. In the further development of the dis- 
ease the essential feature is the coming to the foreground of 
the necrobiotic process and the production of ulcers. 

If we now examine the mouth wc find the yellowish, soft 
seam mentioned before increased in size and resting upon an 
ulcerated surface. When the yellow material is removed with 
cotton there is beneath it denuded membrane, swollen and 
bleeding readily, whose boundary, in its turn, is marked by 
injection even greater than the rest of the mucous membrane. 
Upon this denuded surface there is a goodly quantity of pus, 
but the yellowish material is very adherent to the ulcerated 
surface. The pus may be formed in sufficient quantity to 
pour down between the gum and teeth, so that when pressure 
is applied quite an amount may be forced up, considering the 
size of the affected portion. With these various changes the 
gum is becoming more and more detached from the teeth, so 
that the latter may become loosened. The process, if left to 
itself, continues in the same manner, the seam becoming a 
broad band, the ulcers going deeper, until, finally, the whole 
tooth is denuded. Necrosis of the bone now takes place, in 
either one of the ways described before. When a large por- 
tion of bone has become necrotic we look in upon a compara- 
tively extensively ulcerated surface presenting the character- 
istics above mentioned. In very bad cases the possibility of 
necrosis must be borne in mind, and the examination is not to 
be considered complete until the presence or absence of dead 
bone has been established. Infection of other parts of the 
mucous membrane of the mouth also takes place after the 
ulcers have developed. Infection follows as the result of 
direct contact, and in the majority of cases affects the lower 
lip, then the cheeks, the tongue, and the upper lip. These 
ulcers are the same in every respect as those formed upon the 
gums; they begin with injection, then comes the formation of 
detritus with ulceration, the latter having the peculiar tenden- 



STOMATITIS ULCEKOSA. 81 

cies described before, of which the principal one is that the 
process does not respect the character of tissue upon which it 
happens to develop. In this state the lymphatic glands are 
still more enlarged and frequently very tender upon pressure, 
although rarely inclined to suppurate. Salivation has now 
reached its maximum and the odor is so very offensive that a 
child with this affection may taint the air of a whole room, 
or, when in a ward, it will be found necessary to use disin- 
fectants to neutralize the extremely penetrating fetor. The 
ulcerative process, instead of extending by apposition, will some- 
time- spread directly per continuam, so that we may find it in 
the fold of membrane joining the lower lip to the lower gum. 
Or there may be a space of comparatively healthy tissue be- 
tween the ulcer upon this fold and the ulcerated gum which, 
it seems to me, can only be explained by taking the infectious 
nature of the process into consideration. By gravity the se- 
cretions from the diseased tissue have dropped into this fold, 
they have remained there, and, after a sufficient length of time 
has elapsed, they produce the same process here that has 
occurred before. Reverting to what has been said in connec- 
tion with etiology, it seems that the way in which this disease 
spreads to the rest of the buccal cavity from the gums is proof 
positive of the infectious character of the disease. In all 
cases it spreads by inoculation, however it may be accom- 
plished; if the process is auto-inoculative it certainly is 
rational to suppose that, in a given patient in whom the same 
conditions exist as in the person affected, transmission of the 
affection is a possibility. 

Upon the whole, stomatitis ulcerosa begins most commonly 
about the lower incisors; although there is no tooth about 
which it docs not begin. In the very great majority of cases 
the disease 6rs1 affects the teeth of the lower jaw, although 
this is a rule to which there arc some exceptions. The teeth, 
in -' verer cases, suffer most from the disease; they are denuded, 

6 



82 DISEASES QF THE MOUTH (xOX-SUKGICAE). 

detached from their periosteum, fall out or are pulled out by 
the patient, who finds no difficulty in doing this on account of 
their being so much loosened. 

Restitutio ad integrum may occur at almost any period of 
the disease, either as the result of treatment or, more rarely, 
spontaneously. When this does occur the fetor begins to dis- 
appear, the pnlpous, yellowish mass is thrown off, the ulcer 
beneath it begins to clear up, and a new epithelial covering is 
formed over the place which was affected. When the bone 
has been affected there is more or less permanent loss of tissue; 
when a great portion of the alveolar process has been destroyed 
there remains a permanent loss of teeth, as both the temporary 
and the permanent teeth have been removed with the seques- 
trum. Karely does it occur, as has been mentioned before, 
that the affection becomes chronic. It is more common for 
the affection to begin in a mild degree and remain for a great 
length of time; beginning, if such an expression might be 
used, as a chronic disease. These cases are characterized by a 
milder course, each symptom being less developed. The 
process does not cause the ravages that follow in the acute 
cases, the fetidity of the breath is not so noticeable, and is 
sometimes only present at certain times of the twenty-four 
hours, during the night or in the morning. I have never 
seen necrosis follow in any of these cases, — a statement which 
is also made by Bohn, — and, upon the whole, these cases are 
identical in their clinical appearance with that form of trouble 
which dentists call "shrinking of the gums." They are not 
so easily managed in regard to time, but constant treatment 
usually overcomes the affection. Relapses are the rule, but 
these, with ordinary watchfulness, are also readily cured. 

The differential diagnosis is easy in every case. It fre- 
quently happens that aphthae are developed at the same time 
with stomatitis ulcerosa, but if the clinical picture of both 
affections is kept in sight it is not difficult to say which spot 



STOMATITIS ULCEROSA. 83 

is aphthous and which is that of stomatitis ulcerosa. As be- 
tween these affections, the decision will always be easy except 
in the beginning, when a small aphtha develops just upon the 
same place where stomatitis ulcerosa begins. This, manifestly, 
would be a very rare occurrence, and the difficulty could exist 
in the beginning only; as soon as the aphtha is well devel- 
oped all doubts as to the nature of the process would dis- 
appear. 

Prognosis is influenced by three factors, — the disease upon 
■which stomatitis ulcerosa depends, the stage of the affection 
when the patient comes under treatment, and, lastly, the treat- 
ment itself. When stomatitis ulcerosa is caused by rickets, 
scurvy, or syphilis, it rarely gets well until the constitutional 
affections are removed. The form of rickets which predisposes 
especially to this affection is the so-called acute form, which, 
however, is supposed to be scurvy in young children (Barlow, 
Rehn). Here we have the worst forms and the most intracta- 
ble. One fact must not be lost sight of, — viz., that stomatitis 
ulcerosa may become noma (stomatitis gangrenosa, cancrutn 
oris). On account, of this fact every case of stomatitis ulcerosa 
should be most carefully watched, although this danger exists 
only for debilitated, so-called cachectic children. When necro- 
sis of bone exists the prognosis is changed from that of an 
inflammation of the mouth to that of bone disease. However, 
even here the prognosis is not very bad when the condition 
is recognized, because it can be readily remedied by surgical 
means. 

The iredimeni is both prophylactic and curative. It is 
iry to remove all predisposing causes when possible. 
This consists in improving the general condition of health in 
every respect, — good air, good food, cleanliness. When acase 
occurs in a family the other members must be protected from 
contagion. It is best to do this in all cases, notwithstanding 
tiic Fad that the liability to affection must be very small be- 



Si DISEASES OF THE MOUTH (XOX-SUEGICAE). 

cause of the predisposing conditions necessary to produce the 
disease. When other members of the family are in a debili- 
tated condition from any cause whatsoever, these precautions 
are especially demanded. In such ca^es it is well to give a 
mouth-wash of chlorate of potassium to the uninfected, and 
warn them not to use any utensil which has been used by the 
patient. In this way the spread of the disease is easily pre- 
vented. 

There is hardly any disease which comes under our obser- 
vation of which it can be so positively stated that a cure is 
accomplished by drugs as in the case of stomatitis ulcerosa. 
"We have a remedy which can be looked upon almost as a 
specific. Chlorate of potassium given internally, and admin- 
istered in this way purely for the sake of convenience, acts in 
a definite, well -observed way, and, with few exceptions, renders 
all other medication unnecessary. It is best given in a three- 
per-cent. aqueous solution, with a little syrup, of which from 
one-half to one teaspoonful may be administered every two 
hours, depending upon the age of the patient. There are only 
two objections to this remedy : one, the toxic effects which have 
already been mentioned, and the other the pain that is pro- 
duced when it passes over the inflamed surface. I know of 
no means by which the latter can be prevented ; cocaine has 
its decided disadvantages, besides overcoming the pain only 
partially. Fortunately, this manifestation only lasts a short 
time (from thirty-six to forty-eight hours), and is a positive 
index to the curative effect of the drug. When the chlorate 
of potassium produces its specific effects the symptoms usually 
clear up in a peculiar manner. After the remedy has been 
taken for from twenty-four to thirty-six hours the salivation 
begins to diminish materially; when the patient's mouth is 
opened it will still be found full of saliva, but it no longer 
flows out of the mouth. With the cessation of salivation the 
fetid odor disappears, and in a comparatively short time, 



STOMATITIS ULCEROSA. 85 

usually within a week, all the symptoms have disappeared. 
Now comes the time when the patient must be watched most, 
on account of the danger of relapses; any evidence of ulcera- 
tion, be it ever so slight, demands a continuation of treatment 
or, frequently, the addition of some other remedy. A con- 
tinuance of treatment, however, in mild or moderately severe 
cases forms the exception, not the rule. When ulceration does 
not disappear completely the cause must be found for this ex- 
ceptional condition. This will usually be a carious tooth, which 
must be removed ; if a permanent tooth, it must be treated by 
dental means, and if this does not stop the ulceration recourse 
must be had to cauterization of the gum with silver nitrate, as 
described in connection with the aphthous process. Where 
there is necrosis the sequestrum must be taken away — the 
sooner the better, as the process, although controlled by the 
chlorate of potassium, will break out afresh — or the patient's 
life may be jeopardized. In some cases no apparent cause 
exists for the keeping up of stomatitis ulcerosa ; in these cases 
good results are obtained by the frequent use of potassium 
permanganate, applied with a brush. 

The chronic cases do not respond to potassium chlorate as 
quickly as the acute ones. Even here, however, we get excel- 
lent results when combined with the local treatment just de- 
scribed. Nitrate of silver applied three times a week will 
destroy the specific process, care being taken not to touch more 
than the part affected, and after three or four weeks of treatment 
it will be found that the teeth become more firmly attached 
again and the patient restored. Unfortunately, relapses are 
.veil more common in this form than in the acute; these, 
however, will yield to the treatment just as readily as the first 
attack. 

For the acute form the chlorate of potassium has been so 
completely satisfactory that other remedies, such as salicylic 
acid, aalol, listeriue, thymol, etc., will rarely become necessary, 



86 DISEASES OF THE MOUTH (XOX-SURGICAL.). 

especially if the potassium permanganate is used. It is hardly 
necessary to add, although highly important, that in order to 
prevent relapses the general condition of the patient must be 
looked to, although in the attack itself the administration of 
tonics or reconstructives seems to have little or no effect. 



STOMATITIS GANGRENOSA. 87 



STOMATITIS GANGRENOSA. 

Stomatitis gangrenosa is a disease which may occur at 
any time of life, but is most commonly a children's affection, 
being found most frequently between the ages of three and 
seven years. In German it is called noma, which term is 
employed by the French, although they also use stomatite gan- 
greneuse. English writers speak of the affection as cancrum 
oris, gangrene of the mouth, gangrenous stomatitis, and noma. 
Up to the present time we are not in possession of sufficient 
accurate knowledge to say definitely whether any gangrenous 
process which occurs upon the gums and cheeks is to be 
called cancrum oris or not. From clinical evidences it is most 
likely that a specific process goes on in those cases which are 
'•ailed noma, although it would be, manifestly, improper to 
exclude any gangrenous process from this classification until 
the cause of the whole process is accurately determined. Some 
knowledge has been recently contributed to the etiology of 
this disease by Lingard {Lancet, 1888) and Eanke (Jahrb. 
f. l\"ni<hrlt(jlkunde, III. xxvii., 1888), which permits us to 
hope that in the future this disease will be better understood 
than it is at the present day. 

The affection is a comparatively rare one; in my own 
experience one case in about five thousand, Ranke (loc. cit.) 
states that in eleven years in Munich, seeing from four thou- 
sand to five thousand children yearly, he has seen only two cases 
(this in dispensary practice). The disease is a little more com- 
mon in hospital experience, as bad cases are more frequently 
seen in hospital practice; in private practice the frequency 
depends very lnneli upon external surroundings. 

When we speak of stomatitis gangrenosa we mean a gan- 



88 DISEASES OF THE MOUTH (XOX-SURGIOAL.). 

grenous process which begins upon the gums or inner side of 
the cheek, spreading with great rapidity so as to involve the 
whole substance of the cheek, and extending more or less to 
the surrounding tissues. 

Etiology. — The first question to be answered is as to the infec- 
tious nature of the disease. There are a great many instances 
upon record in which the process has occurred in one ward of a 
hospital, in several members of a family, etc., so that evidence 
in this direction exists of the infectious nature of the affection. 
Again, on the other hand, every one who has seen any cases 
at all will have seen such in which it was impossible for the 
patient to have come into contact with any one who had had a 
gangrenous process of any kind. The experience of any one 
individual is too small to decide this question definitely, yet I 
venture to state that most physicians would answer it nega- 
tively. There are many things which speak in favor of the 
infectious nature of the disease : that it has occurred as stated 
above; that the process usually occurs, primarily, at the junc- 
tion of the skin with mucous membranes, the anus, the geni- 
tals, the mouth, where infection takes place most readily 
(Gerhard); that the disease is found in affections in which the 
mucous membranes are in the best possible condition for the 
reception of infectious material. But proof, except by infer- 
ence, is still wanting. There can be no doubt of the fact that 
cancrurn oris occurs spontaneously without the existence of 
previous cases. 

No disease exists in which the predisposing cause is accepted 
so universally as in stomatitis gangrenosa. This predisposi- 
tion consists in a reduction of health in a way which, for the 
present, cannot be accurately defined. Ranke says concern- 
ing it, "AYe know that other carriers of infection require a 
certain amount of predisposition in order to develop their 
functions. In this direction the supposed virus of noma 
would have to be placed at the extreme end of the list of 



STOMATITIS GANGRENOSA. 89 

infectious agents. It would be necessary to premise that its 
attacks upon a healthy cell would be absolutely futile, and that 
it can manifest its effects only upon extremely-weakened cells." 
From a clinical stand-point we know that the weakening of the 
cells is produced by certain diseases : the acute exanthemata, 
especially measles (forty per cent, of all cases, Barthez and 
Rilliet), long-continued fevers and infectious diseases, typhus, 
whooping-cough, syphilis and scorbutus, chronic intestinal ca- 
tarrhs and malaria. To this must be added the excessive use of 
mercurials, although this causative factor was very much over- 
estimated in former days. Bohn has shown the importance 
of stomatitis ulcerosa as an etiological factor for noma, pos- 
sibly as its forerunner, and therefore of great importance; but 
the connection between the two disenses in all probability 
ceases there. Malaria is looked upon by Hirsch as of prime 
importance, simply from geographical evidence; and while it 
cannot lie denied that the reduction of general health may be 
produced by malaria, the direct cause must be found in some- 
thing else. In general terms it may be stated that all those 
predisposing causes which have beeu enumerated under stoma- 
titis ulcerosa are accepted for stomatitis gangrenosa. The fact, 
however, must be insisted upon that predisposition is so 
important that in any given case of noma the general con- 
dition of the patient would immediately be noticed by any 
physician, and would be a source of alarm upon very cursory 
inspection. 

Investigations as to the direct cause are as yet in their 
infancy. Cornil and Babes make the statement that short 
streptococci are found in stomatitis gangrenosa, and, in certain 
cases, rod-; like those <>f pulmonary gangrene. No allusion is 
made i<> cultures or inoculations by these authors. Ranke 
(foe. dl.) has found streptococci resembling those described by 
Koch as producing progressive tissue-necrosis in field-mice. 
lie has made no cultures, but has inoculated rabbits with 



90 DISEASES OF THE MOUTH (NON-SURGICAL). 

pieces of tissue taken from the immediate neighborhood of the 
gangrenous process. The animals died, hut in no instance 
was he able to produce gangrene, so that in his conclusions, at 
the end of his paper, Ranke states that " up to the present the 
specific nature of the cocci present in cancrum oris has not 
been proven." Lingard (loc. cit.) found bacilli in thread-like 
growth 0.004 mm.-0.008 mm. long, 0.001 thick. Cultures 
were made as well as inoculations. Young pigs and calves 
were killed by these inoculations on the tenth and eleventh 
days, and septic lesions of the heart were produced. No state- 
ment is made concerning the production of gangrene except 
that the lower forms of life were also found in certain petechial 
spots in the human subject. It is difficult to judge of these 
results, as the heading of the article is " Cancrum Oris or 
Ulcerative Stomatitis," terms which, according to our view, 
are not synonymous. As, however, the term cancrum oris is 
so distinctive it has seemed to us that only the gangrenous 
process could be referred to. 

It would be rash to try to bring these various observations 
into accord, the one with the other; as a resume it might be 
well to state that all these observers have found lower forms 
of life in noma. Ranke has found them within the tissues; 
Lingard has cultivated them ; both have killed animals, the one 
by inoculating them with the tissue, the other by injecting cul- 
tures. In no instance M T as there produced anything resembling 
the pathological changes of noma, although Ranke introduced 
a piece of diseased tissue under the mucous membrane of 
the month. It is impossible to state whether the poison has 
been isolated by Lingard or whether he has found the virus of 
something else. His description does not correspond with the 
one given by Fruhwald (Jahrb. f. Kinderheilkunde, II. xxix., 
1889) for a bacillus found in ulcerative stomatitis, and does uot 
agree with the pictures seen by Ranke. Knowing, as we do, 
the absolute importance of a predisposing cause, it is futile to 



STOMATITIS GANGRENOSA. 91 

discuss the method by which the direct cause acts before this 
cause has been isolated, so that the question cannot be defi- 
nitely answered whether it comes from within the system as a 
poison of some sort, or from without as a lower form of life. 

In the very great majority of cases some lesion is found upon 
the mucous membrane of the mouth which precedes the attack 
of gangrene. In some instances no lesion could be found, but 
on account of the locality of the process it has been found 
impossible to exclude such with absolute certainty. The case 
which has often been quoted from Gierke's article (Jahrb. f. 
Eanderheilkunde, X. F. 5, p. 269) as opposed to this view cannot 
be considered in this light, as the gangrenous process evidently 
arose from a stomatitis ulcerosa. The appearance of gangren- 
ous spots upon the skin, in this case, could be readily explained 
if the assumption of a specific virus is accepted. 

Pathological anatomy. — The process is one of rapid phleg- 
monous gangrene. Around that portion which has been de- 
stroyed there is found an infiltrated zone (Ranke, loc. cit.). This 
is characterized by true necrobiosis ; all evidence of pre-existing 
tissue has disappeared under the microscope; in its stead there 
is found a perfectly homogeneous substance which shades off 
in the direction of the adjacent tissue. This homogeneous 
substance is already dead, and around it we find the connective 
tissue increased, its corpuscles in cell division and its blood- 
vessels closed by thrombi. The micrococci are found both in 
the homogeneous as well as in the proliferated tissues. Ranke 
has made interesting observations concerning the karyokinetic 
figures which, as he states, are found both in the fixed as well 
as in the wandering connective-tissue corpuscles and in the 
muscle cells within the proliferated zone. 

Symptomatology. I. General. — These symptoms vary very 
much, depending upon the disease upon which noma is 
ingrafted, for a healthy child cannot be attacked by noma. 
It may be Stated that the intensity of the general symptoms is 



92 DISEASES OF THE MOUTH (NON-SURGICAL). 

in direct ratio to the severity of the disease. A great many cases 
are upon record in which the children seemed in the beginning 
to be very little affected by the development of noma. Bohn 
gives a description of this condition which leads one to infer 
that the children, in this disease, are rather cheerful than 
otherwise. While the fact exists that frequently patients will be 
attacked by stomatitis gangrenosa and pay very little attention 
to the local process, pulling out loose teeth, picking off pieces 
of gangrenous tissue, etc., in a very short time general symp- 
toms supervene which show that we are dealing with a process 
which produces a very deep impression upon the general con- 
dition. Fever may not be present in the beginning, but 
develops sooner or later, reaching 104° to 106°, becoming 
hectic, especially when suppuration is present, and before death 
the temperature frequently falls to subnormal. The pulse 
usually follows the temperature, but throughout is weak, easily 
compressible, and small. Diarrhoea is present in almost every 
case. This diarrhoea is of the most intractable variety, and, as 
Gierke has pointed out, must be due to the swallowing of 
material from the diseased surface in the mouth. Lesions in 
the organs are also common, especially catarrhal pneumonia, 
probably due to the entrance of septic material into the bron- 
chial tubes. Diphtheria has been observed in several cases 
(West, Gierke). As a result of the general infection, the 
local symptoms, the fever, the diarrhoea, death usually comes 
to the patient by exhaustion. The children then become 
apathetic, refuse all nourishment, are restless, and finally die in 
collapse. The nervous system is rarely implicated even in 
the worst cases. 

II. Local. — The local process usually begins suddenly : if 
the result of a stomatitis ulcerosa, the symptoms of ulceration 
are changed to those of gangrene; if upon a comparatively 
healthy mucous membrane, the physician can never be in doubt 
as to the nature of the process. It is essentially a moist gan- 



STOMATITIS GANGRENOSA. 93 

grenous process and characterized by all the symptoms of this 
condition. The beginning of the process is to be found, usually, 
upon the gums or upon the inner surface of the cheek, near 
the corner of the mouth, and, it is said, more frequently upon 
the left than upon the right side. Possibly the first thing that 
will strike the observer is the appearance of the peculiar odor 
of gangrene; if stomatitis ulcerosa has preceded the develop- 
ment of noma, the fetor of the former disease is covered over 
by the intense and penetrating odor of noma. Upon exami- 
nation there will be found at the point of development an 
ulcer, gangrenous, which spreads with great rapidity. Very 
soon the cheek begins to swell so that if taken between the 
thumb and forefinger it will be felt to be thickened through- 
out its entire structure. This swelling is more or less cedema- 
tous, the skin becomes waxy, and in a very short time, some- 
times within twenty-four hours, the whole side of the face up 
to the eyelids and down to the jaw or upon the neck becomes 
involved. This cheek may be painful upon pressure, but more 
commonly the patients do not complain of painful sensations. 
If we now look at the ulcer within the mouth we see that it 
has grown very much in depth, evidently eating its way 
through the substance of the cheek. As it comes near the 
integumentary surface, symptoms of its approach begin to 
manifest themselves upon the skin. The latter becomes dis- 
colored, red, blue, purple, black, or a combination of several 
shades. The reddish tint is usually observed in the beginning, 
and the spol of gangrene may be surrounded by a red areola. 
When the gangrenous process is completed there is always 
developed a dark spot. In a great many cases a bulla is 
formed, over the spot to become affected with gangrene, filled 
with ichorous fluid. The epithelial covering breaks and, with 
this, perforation of the cheek takes place. In cast] the bulla 
has not formed, melting away of the tissue- lakes place in one 
direction only, from within outward, the skin then may 



( J1 DISEASES OF THE MOUTH (NON-SURGICAL). 

become mummified, but is finally softened and breaks down. 
Rarely is the gangrenous process completed when perforation 
has taken place ; in one case which came under my observation, 
resulting from chronic malaria, there was what appeared as a 
cleanly-cut, oval hole. The rule is that the process now 
extends, involving the soft parts of the cheek, going down 
upon the neck, eating into the nose, the eyelids, affecting the 
frontal bone, destroying the eye, but rarely extending to the 
other side. In the mouth the devastation is apparently greater 
than upon the surface. "While we find the destruction within 
the mouth to be very great in all cases, upon the surface it 
may be comparatively limited. Nothing is spared ; the bones 
are denuded, the teeth loosened, the tongue and hard palate 
may become affected, even the soft palate and the tonsils may 
become involved. The whole is converted into a black, fetid, 
pulpous mass. The patient may now be considered in a fright- 
ful condition, and there is hardly any sight so repulsive as a 
child with well-developed noma. If to this appearance there 
is added, as is not infrequently the case, the entire apathy of 
the child for the local condition, we have a combination which 
calls for the utmost sympathy on the part of the surroundings. 

With all these changes the patient complains little of the 
local condition. The flow of saliva is very much increased ; afc 
first the patient swallows very well, but ceases to do this as the 
disease progresses. Again, the appetite may not be diminished ; 
but this also disappears in a short time. The odor that fills 
the room is frightful ; the whole house is sometimes filled with 
it, so that the diagnosis of gangrene can be made as one enters 
at the front door. Hemorrhages are quite rare on account of 
the fact that all the blood-vessels are closed by the thrombi. 

The course of the disease tends either to death or, what is 
very much rarer, recovery, either spontaneously or as the re- 
sult of treatment. When death comes it is as the result of the 
general condition. When spontaneous recovery takes place 



STOMATITIS GANGRENOSA. 95 

we find a line of demarcation around the gangrenous spot, the 
surface is finally converted into one covered by grauulative 
tissue, and there takes place cicatrization, leaving frightful 
scar-. This is also very rare. In most cases that have 
recovered it seems that the treatment has had something to 
do with the result. Relapses take place, but they are com- 
paratively rare, — two cases out of twenty. (Gierke.) 

The duration of noma varies from one to two weeks, but 
sometimes very much longer. Perforation of the cheek has 
taken place in as short a time as twenty-four hours, but usually 
takes three or four days. 

Prognosis. — It is almost useless to discuss the factors which 
go to make up our prognosis in a case of noma, as nearly all 
cases die. The mortality is given as ranging from seventy per 
cent, to ninety per cent, of all cases affected. The statement 
can be made that the more intense the local process the greater 
the mortality. This seems paradoxical, yet the fact must not be 
lost sight of that when gangrene ceases, the patient still being 
alive and not affected by complications, the general condition 
upon which the final result depends must certainly become 
improved. Complications, especially catarrhal pneumonia or 
diphtheria, will render our prognosis absolutely unfavorable. 

Treatment. I. Prophylactic. — Unfortunately, little can be 
done in this direction. The disease may develop when and 
where it is least expected. Its development is very sudden, 
and, as has been stated, it may develop in patients whose 
mouths are apparently perfectly healthy. On account of the 
rarity of the affection the physician does not think of noma, 
and, fortunately, this is not necessary. In hospital practice the 
careful watching of individual cases, their possible isolation 
combined with antisepsis, are certainly of value. The modern 
hospital, however, can hardly be charged with epidemics of 
noma, at least there are none such upon record. 

The treatment of a case which has developed can resolve 



96 DISEASES OF THE MOUTH (NON-SURGICAL). 

itself into two principal divisions, — 1, the general; 2, the 
local treatment. 

Of the general treatment little need be said. The disease is 
found in reduced subjects, usually in such which have been 
worked at by physicians precisely in that direction which 
seems needful for the cure of noma, — the improvement of gen- 
eral health. The indications in every case are to keep up the 
strength of the patient until it has become possible to make 
the attempt to cure the local process. The tonics and stimu- 
lants would come into play here, but always with the needed 
precaution not to disturb the digestion. The patient must be 
fed with condensed, nutritious food, if necessary predigested. 

The local treatment has resolved itself to an artificial limi- 
tation of the gangrenous process by substituting an artificial 
destruction of tissue. For this purpose a great many sub- 
stances have been employed. It is essential that the remedies 
be used as early as possible. Barthez and Rilliet, as well as 
others, state that the caustic ought to be used " before the deep 
tissues of the cheek are invaded." The caustics which seem to 
enjoy the greatest reputation are hydrochloric acid, then nitric 
acid (West). Evanson and Maunsell report good results from 
the local application of sulphate of copper in six-per-cent. 
solution. The same authors also speak highly of sulphate of 
zinc in twelve-per-cent. solution. But it has always seemed to 
me that if anything is to be accomplished by treatment at all, 
in this disease, we ought to have recourse to those remedies 
which act quickly, deeply, and thoroughly. For this purpose 
caustics must be used whose action is intense, destroying that 
with which they come into contact and producing distinct re- 
action. These caustics can be divided into chemical and 
thermal. Of the latter class we have the white-hot iron, the 
galvano-caustic wire, and the Pacquelin cautery. The chemical 
caustics that have been used are either in solid or fluid form, 
and nearly every chemical has been used that has caustic prop- 



STOMATITIS GANGRENOSA. 97 

erties. Of the thermal caustics it has been said that their 
application is difficult and their action inexact because we 
could not tell where to find healthy tissue. The same objec- 
tions (Bohn) have been raised against fluid chemicals, and 
Boh n therefore recommends nitrate of silver in stick. The 
great advantage of nitrate of silver, applied in this way, is 
that it does not attack healthy tissue more than seems neces- 
sary, but destroys all that is dead or becoming gangrenous 
(just as it acts in lupus vulgaris). The only objection to the 
use of nitrate of silver is whether its action upon the healthy 
tissue is sufficiently energetic to produce any benefit. If the 
indication is to cause deep destruction of healthy tissue, so as 
to produce demarcation well marked, the nitrate of silver can- 
not be relied upon. It is certainly a fact that some cases of 
noma will get well spontaneously : the only case I have ever 
seen recover did so with applications of a solution of per- 
manganate of potassium without the use of any cautery, and 
therefore not all cases of recovery are to be attributed to the 
remedy u<cd. In the two cases of recovery of Gierke, chloride 
of zinc and pyrol igneous acid were used ; Foerster (Jakrb. f. 
Kinderheilkunde, v. p. 328) reports a case which was cauterized 
by using dilute muriatic acid, then nitrate of silver in stick, 
and finally in solution. The results of Evanson and Maunsell, 
referred to in high terms and corroborated by J. Lewis Smith, 
certainly show that some patients will get well without very 
much treatment, certainly without cauterization. As far as I 
am concerned, I would not like to take the risk of treating any 
case of noma without the use of a caustic of some sort. It 
seems to me that with the very bad prognosis, quoad rilam, 
the destruction of a little more or less tissue ought not to be 
taken into consideration at all, especially when we bear in mind 
that much more tissue is already dead than appears when we 
judge by the classical gangrene color only. The object of cau- 
terization must be to destroy not only the waxy /.one, but to 

7 



98 DISEASES OF THE MOUTH (NON-SURGICAL). 

go into the tissue, for some distance, that seems perfectly 
healthy, if we can dare to hope for setting up a process of 
repair, or dosing up the lymphatics against further invasion. 

If circumstances permit, the patient should be anaesthetized 
before the caustic is employed. This is frequently inexpedient 
on account of the great weakness of the patient. Before the 
caustic is applied all the necrotic tissue should be removed 
with forceps and scissors, and then the operator is ready. The 
galvano-caustic wire or Pacquelin's thermo-cautery seem to me 
to offer advantages that are not afforded by any other means. 
Their action can be limited, they can be made to act as deeply 
or as superficially as the operator may choose. It is necessary 
to take into consideration that when the cautery is applied when 
it should be, the inner surface of the cheek is the place where it 
will be used most frequently. It will immediately be seen how 
readily this can be done with either of these instruments when 
it would be very awkward with a fluid acid and very difficult 
with any of the fluid pastes. The question of how often the 
tissue should be cauterized has been answered : not more fre- 
quently than once in twenty-four hours. There certainly can- 
not be any law put down, as every case is a law unto itself. 
With cauterization the ordinary antiseptic methods of treating 
wounds will be sufficient local treatment for most cases of 
noma. Sometimes poultices will be required, sometimes the 
granulating surfaces will need to be treated. The surgical 
treatment of the cicatrices ought to be put off as long as pos- 
sible, as it has been found that plastic operations do not suc- 
ceed very well when performed early upon patients that have 
had noma, and also that noma may recur as the result of these 
operations. 

It is unnecessary to add that the outlook, with all methods, 
with everything in apparently good condition, remains unfavor- 
able to the patient, do what we will and do it as we will. 



STOMATITIS CKOUPOSA STOMATITIS DIPHTHERITICA. 99 

VI. 

STOMATITIS CEOUPOSA— STOMATITIS DIPHTHERITICA. 

It is not the province of these articles to enter into the dis- 
cussion concerning the identity of croup and diphtheria. The 
opinion which is held by any individual upon this question de- 
pends upon a variety of circumstances, not the least important 
of which seems to be the kinds of cases which have come under 
his observation. Some clinicians (and their number is not 
small) have not been satisfied with the decisions that have 
been handed down by those who were formerly looked upon 
as authoritative, — the pathologists, — and with more or less 
powerful arguments, always clinical in their nature, have rea- 
soned themselves into the view of the identity of the croupous 
and diphtheritic process. Others, on the other hand (and 
again their number is not small), who have seen what they 
considered as pure and uncomplicated croup cases, for which 
they, in their turn, have advanced clinical arguments, have in- 
sisted upon a separation of the two processes as non-identical. 
As we no longer look upon the pathological anatomist as the 
supreme judge to whom the last appeal is made, and as we 
certainly have no right to decide questions of etiology by 
purely clinical observation, the whole discussion has resolved 
itself into a matter of scientific belief, which, although a con- 
tradiction in terms, is of wide-spread existence. From this 
stand-point it may not be improper to state that the author be- 
lieves that the diphtheritic and croupous processes, while fre- 
quently combined, are in their nature: two essentially different 
entities, caused by different agents and followed by different 
results in the human being. 

At the preseni day the court of appeal is made up of bac- 
teriologists with chemists (the latter in the minority), who 



100 DISEASES OF THE MOUTH (nOX-SURGICAL). 

have not, as yet, passed their verdict upon the mooted points. 
It is by no means positive that when this will occur it will 
be final for all time, but for us the question will be settled 
when this is satisfactorily done, if such is possible, by these 
jurors. 

Stomatitis crouposa is always a complication of angina 
crouposa. As far as the literature and my own experience 
goes, I know of no case of primary croupous inflammation of 
the mouth. In a great number of cases of angina crouposa the 
membrane develops simultaneously upon the tonsils and adja- 
cent parts of the mouth. In severe cases extension takes 
place to the tongue, the lips, and the cheeks (Steiner). One 
of the characteristics of this process is the comparatively 
slight involvement of the lymphatic glands. We find this 
in stomatitis crouposa as well as in croup in other locations. 
As the disease is part of another disease of very much greater 
importance, and as it does very little, if any, damage by itself, its 
prognosis can be of importance only in that it indicates by its 
presence the intensity of the condition which affects the patient. 
There is little, if any, treatment required for the stomatitis be- 
yond the one used for the angina. When the membrane has 
been shed, it will sometimes be found necessary to apply some 
of the remedies which have already been recommended in 
those cases in which there exist superficial ulcers of the 
mucous membrane of the mouth, although these are exceptional. 

STOMATITIS DIPHTHERITICA. 

In birds and in the calf stomatitis diphtheritica is the 
most common form of deposit of diphtheritic membrane. 
In the human being primary diphtheria of the mouth is ex- 
tremely rare; yet cases do occur, and one especially is of 
great interest (found in Gustin, " Etude Clinique sur lTn- 
oculabilite de la Diphtherie," Paris, 1883, and Sanne, "Dic- 
tionnaire Encyclopedique," iii. p. 29). The case was origi- 



STOMATITIS CROUPOSA — STOMATITIS DIPHTHERITICA. 101 

nally reported in the Union Medicale, 1859, by Professor G. 
See. A wet-nurse was nursing her own child, ten months 
old, and a little girl who had diphtheria of the vulva and 
of the lips. Several days after the latter w r as taken sick the 
nurse's own child began to complain of the same series of 
symptoms, — i.e., diphtheria of the lips, — which was followed 
by angina diphtheritica and croup, the latter fatal. The mother, 
who persisted in kissing her child, was also taken with diph- 
theria of the lips, but the disease remained localized to this 
place. Another child was also affected with diphtheria, but 
there was produced, from the start, an angina diphtheritica. 
The nipples and breasts of the mother remained normal 
throughout the whole course of the disease. The case is of 
interest not only because of the number of interesting cases 
connected with it, but also on account of the fact that we have 
three cases of primary diphtheria of the mouth. Although 
cases of this sort are extremely rare, yet they must be more 
frequent than would be inferred from the very few cases upon 
record. The statements made by the best authors — Jacobi, 
Seitz, Baginsky, and others — lead us to the conclusion that 
they have seen cases of primary diphtheria of the mouth, al- 
though, as Jacobi says, "diphtheria of the mouth (primary) is 
not very common, but is not infrequent with diphtheria of the 
pharynx or nose.''* Sann6 says that in epidemics it is not rare 
that the mouth is affected primarily. When infection has 
taken place by the mouth the lips are usually the first to be- 
come affected. From here the membrane may extend to any 
pari of the mouth or to the tonsils. 

In diphtheria of the tonsils, when the membrane extends to 
ili'' mouth, we usually sec the following method of invasion: 
first, the pillars of tin- fauces, perhaps more commonly simul- 
taneous with the angina; then tin; tongue, cheeks, lips, and 
gums. This, however, is Subject to a great many exceptions, 

lor example, the case reported by Scitz(" Diphtheric u. Croup," 



102 DISEASES OF THE HOimi (NON-SURGICAL). 

1877, p. 312). The membrane was first noticed upon the left 
tonsil ; then upon the gum at the last right incisor tooth ; then 
upon the right side upon the dorsum of the tongue, at the same 
time diphtheria of the nose. Those cases are apt to be accom- 
panied by diphtheria of the mouth in which the general infec- 
tion is very great, in so-called septic cases. It is pretty well 
established that diphtheria cannot be inoculated upon a healthy 
mucous membrane (Rajewsky, Loeffler, and others), and there- 
fore it is necessary to conceive of some alteration of the mucous 
membrane of the mouth before it can become diphtheritic. 
This is not difficult in diphtheria, and the clinical evidence 
will confirm all that is necessary to make a mouth diphthe- 
ritic. In all cases of diphtheria more or less profound changes 
go on in the mucous membrane of the mouth, — from a simple 
injection or dryness to a stomatitis of one kind or another. It 
is a matter of astonishment that stomatitis diphtheritica docs 
not occur more frequently than is the case, when we take into 
consideration that the membrane which is expectorated almost 
always comes into contact with a mucous membrane ready to 
have the seed for further growth implanted upon it. The fre- 
quency of invasion of the mouth can be approximately stated 
by referring to a table published by Minnich (" Croup u. seine 
Stelluug zur Diphtheritis," Wien, 1888), in which three cases 
of thirty-seven of diphtheria had stomatitis diphtheritica. 
When, however, the mucous membrane of the mouth becomes 
diphtheritic we always find accompanying the process a stom- 
atitis catarrhal is, which is independent of any condition there 
may have been present before the diphtheria had developed. 

Salivation is an almost constant symptom, accompanied by 
a fetid odor from the mouth, the same which is noticed in 
angina diphtheritica, in well-developed cases. Before the 
eruption of the membrane the place upon which it develops 
becomes very much injected, almost livid, and in a compara- 
tively short time (from twelve to twenty-four hours) we see 



STOMATITIS CROUPOSA — STOMATITIS DIPHTHERITICA. 103 

upon or within this injected area the characteristic membrane. 
This membrane, depending somewhat upon the intensity of 
the process, may appear as discrete spots which afterwards 
confluesce, or the whole livid area may immediately be cov- 
ered in its full extent by one membrane. At the same time 
there is marked swelling of the lymphatic glands under the 
jaw, accompanied by more or less tenderness upon pressure. 
In septic cases, frequently the general condition of the patient 
is such that subjective signs are of no especial value, or they 
do not exist. The membrane remains for a variable time, — 
three to five or six days, — and then either drops off or ulcer- 
ates away. In either instance there is left a denuded spot, 
where the epithelium is absent, and, depending upon the 
amount of ulceration, more or less loss of substance. As a 
rule, cicatrices do not occur, but sometimes the loss of sub- 
stance becomes great and then connective tissue is formed ; 
especially is this the case upon the tongue. During the whole 
process there is a continuous flow of saliva, which may erode 
the skin with which it comes into contact. At the corners of 
the mouth it is not uncommon to find a diphtheritic patch, 
and sometimes the diphtheritic process will extend to the skin 
upon either the upper or lower lip. 

Hemorrhages occur with this form of stomatitis, sometimes 
severe, at other times the loss of blood is not very great; they 
are always of bad prognostic omen, for they mean general in- 
fection of great intensity. The oozing out of a few drops of 
blood from the mucous membrane in a diphtheritic patient, 
especially when due to mechanical irritation, of course means 
nothing ; but there are cases upon record in which the patient 
has lost his life directly by hemorrhage from the mouth, and 
;i great many more in which a slight hemorrhage seemed to 
be sufficient to destroy the last spark of vitality left to the 
debilitated subject. (Sec 8ann6, loc. tit.) 

The prognosis is besl expressed with Jacobi (loc cit.), that 



104 DISEASES OF THE MOUTH (xON-SUKGICAL). 

"under all circumstances stomatitis diphtheritica is of a dan- 
gerous nature." In primary cases the prognosis seems better 
than in those in which the membrane has extended from other 
parts. Such cases are so very rare, however, that they need 
hardly to be taken into consideration when generalizing upon 
the subject. It seems necessary to state that the localization 
of the membrane has very little, if any, effect upon the pro- 
duction of sequelae or upon the possible development of 
complications. 

The treatment is the same as that for any other form of 
diphtheria; but Baginsky's statement that this process "chal- 
lenges local therapy" is one that ought to be borne in mind. 
Every physician who has dealt largely with diphtheria has 
selected for himself the local remedy upon which he places the 
most reliance. These are the cases in which he can test this 
remedy and see how valuable it is. There is no difficulty in 
removing the membrane, accessible as it is to all local medica- 
tion, and for this purpose a great number of remedies can be 
used : carbolic acid, corrosive sublimate, nitrate of silver, the 
persalts of iron, permanganate of potassium, trypsin, papayotin, 
etc. The great question, after all, is whether the removal of 
the membrane will do the patient any good. When we are 
dealing with a case in which the constitutional effect is not 
very great, or even moderately severe, I have no hesitation in 
saying that the indication exists for the removal of the mem- 
brane. When, on the other hand, severe constitutional symp- 
toms exist, the local treatment of diphtheria is futile and, 
sometimes, harmful. In such cases time cannot be wasted nor 
the strength of the patient be dissipated by attempts at de- 
struction of the membrane. Unfortunately, whatever is done 
is for naught, in the great majority of such patients; but, at 
all events, attempts should be made to treat the general condi- 
tion which is the one producing the most serious and, most 
frequently, the only issue, — death. 



STOMATITIS SYPHILITICA. 105 



VII. 

STOMATITIS SYPHILITICA. 

It is almost unnecessary to state that, strictly speaking, there 
is no such process as stomatitis syphilitica. Syphilis, per se, 
does not produce stomatitis except in an indirect way, in that 
it may either cause the mucous membrane of the mouth to be- 
come more sensitive to stomatitis producers, or in that it causes 
a lesion of some sort which, in its turn, provokes inflammation. 
The term has been retained in our classification for the sake of 
convenience and because it is found extensively employed in 
the literature of stomatitis. 

Syphilis manifests itself in and about the mouth in well- 
defined forms and in well-recognized localities. The localities 
that are especially apt to be affected are the lips, the tongue, the 
tonsils, and the mucous membrane covering the cheeks. The 
teeth, it is claimed, are subject to the general law of the char- 
acteristic nature of the syphilitic lesion, but this is still open to 
discussion. It is quite difficult to lay down an absolute law 
which will hold good in every case, so that we may be guided 
by it for diagnostic purposes. If we hold fast to specificity of 
lesions produced by syphilis, there are cases in which it be- 
comes absolutely impossible to make a diagnosis of syphilis 
simply by an examination of the patient. Again, if we rely 
upon the statements made by parents, we are in danger of 
erring in two directions, — either in considering a manifestation 
as syphilitic when it is not, or, more commonly, of overlooking 
a specific manifestation entirely. Fortunately, these combina- 
tions can only arise exceptionally, for, as a rule, the patient 
may be observed for some time, and we have collateral cvi- 
dence which guides us much more safely than the admission 
or denial of the parent-, [f we except the teeth, the lesions 



106 DISEASES OF THE MOUTH (NON-SURGICAL). 

in the mouth are nearly all characteristic, and no doubt can 
arise as to the general diagnosis in their presence. 

Syphilis manifests itself upon the lips in one or other of the 
following forms: syphilitic fissures, papules, plaques, and ero- 
sions. The fissures (rhagades) represent the most common 
specific manifestation upon the lips. When they are present 
they are absolutely characteristic and leave no doubt as to the 
diagnosis. They are characterized by their location, their ap- 
pearance, and their duration. The most common place of ap- 
pearance is the corner of the mouth, then the upper lip and, 
comparatively rarely, the lower lip. Upon the upper lip we 
usually find them upon either side of the median line, and 
they differ somewhat from those found at the corner of the 
mouth. In the latter place, as a rule, the most striking thing 
about the fissure is that we are dealing with infiltration which 
has been split in or about its middle. The fissure "sometimes 
loses itself in the mucous membrane, sometimes stops before 
reaching it, sometimes runs into the mucous membrane, as in 
the case of the fissures upon the lips. The infiltration (small- 
celled) is somewhat elevated, the fissure may or may not be cov- 
ered by a crust, and, contrary to most syphilitic eruptions, pro- 
duces more or less pain when the mouth is opened. On account 
of the crack's being connected with the mucous membrane, small 
hemorrhages may occur, and the crust may therefore be made 
up of coagulated blood which has extraneous matter mixed 
with it. These rhagades do not secrete very much unless 
they are made up of papules, when their surfaces as well as 
the fissures are apt to be moist. This form is rarely found 
upon the upper lip, where the fissures are characterized by the 
lack of infiltration, but the fissure usually ends in an infiltra- 
tion upon the mucous membrane. If we turn up a lip upon 
which there is such a fissure the rhagade will be found to end 
in some form of syphilitic lesion upon the inner surface. This 
class of fissures is sometimes present in great numbers, dis- 



STOMATITIS SYPHILITICA. 107 

figuring the mouth and causing great annoyance to the patient. 
All rhagades are characterized by their persistency and by their 
lack of tendency to spontaneous healing. Those found upon 
the lip, although they do not secrete more than the form 
at the commissure, are even more persistent. They may cause 
disfigurement of the lip because of the inflammation which is 
caused by them, which, when they heal, always produces cica- 
trices. Again, the fissures may be so deep and so numerous 
that by their presence alone the whole shape of the mouth is 
changed. 

Papules are most commonly found at the commissure, al- 
though the free border of the lip is sometimes infiltrated and 
thickened by a broad papular eruption. As stated above, they 
may have a fissure upon them, but usually they are found in 
the form of condylomata lata. Their surface is elevated and 
moist ; their tendency is to break down in the centre, producing 
an ulcer which is covered by a crust. When this crust is re- 
moved there is found the ulcerated surface, which does not 
bleed very much. The papules, in and of themselves, produce 
very little pain unless they involve the mucous membrane. 

Plaques muqueuses and erosions are found upon the mucous 
membrane. They are both superficial, but cover more space 
than any of the forms described before. The infiltration is 
not so well marked, but nevertheless there is more or less 
thickening present. 

('poii the tongue there are found various lesions, some well 
known and thoroughly accepted as characteristic, others suffi- 
ciently characteristic as lesions but not as syphilitic lesions. 
Among those which are accepted by all are the various mani- 
festations with which we have become acquainted in discussing 
the alterations upon the lips. The most common varieties 
found upon the tongue are : the plaques muqueuses and syphi- 
litic ulcers. Both have infiltrated edges, but the plaques, in 
this Bltuation, are raised above the level of the tongue, while 



108 DISEASES OF THE MOUTH (NON-SURGICAL). 

the ulcers are considerably depressed. Either one or the other 
form is characteristic and sufficient for a diagnosis of syphilis. 
Their localization depends somewhat upon the presence of an 
irritation, so that we find them opposite sharp teeth, but they 
may occur upon any part of the tongue without any especial 
cause being determinable. 

There is no reason why the so-called primary sore could not 
develop upon the tongue of the child, and, certainly, such has 
occurred. As it would not differ from that in the adult, there 
is no especial interest attached to it. Children contracting 
syphilis from their nurses have the first manifestation either 
upon the lips or upon the tongue. When an ulcer which 
occupies a greater part or the whole of the tip of the tongue is 
present it is always suspicious, and when, in addition to the 
locality, a decided infiltration is present, the diagnosis is 
almost complete. 

Among the manifestations upon the tongue which are fre- 
quently overlooked must be mentioned certain changes which 
go on in the epithelium. They are not characteristic of 
syphilis, but they are usually present in the early period. 
They cousist in a loss of epithelium which especially affects the 
mucous membrane covering the filiform papillae and the inter- 
papillary coating. As a result of this loss, the tongue takes 
upon itself a " shaven" appearance, it is redder and dryer than 
usual, and careful inspection reveals an absence of filiform 
papilla? with a corresponding prominence of the fungiform 
papillae. The latter is only comparative, as these papillae 
also have been deprived of their epithelium, but they seem 
to be more prominent because they are all that is left of 
the elevated formations of the tongue. When it is possible to 
get a view of the circumvallate papillae they will be found to 
be very prominent and decidedly enlarged. In infants it is 
difficult to see the base of the tongue, but in older children it 
is very much easier than in adults, and in all cases of syphilis I 



STOMATITIS SYPHILITICA. 109 

have found these papillae very much enlarged, so that in 
some instances my attention has been especially directed to 
them. 

There exists a condition of the tongue which has been fre- 
quently described, but which has received especial attention 
comparatively recently, has been named, and been made char- 
acteristic for syphilis. This condition, called by Parrot (in "Syph- 
ilis Hereditaire et le Rachitis," 1886) desquamative syphi- 
lide of the tongue, is of great interest in all directions. Before 
going on to discuss its relation to syphilis and the evidences of 
such relation, it will be necessary to give a description of the 
condition. It is essentially a children's affection in the sense 
that it begins early in life : further observations will have to be 
recorded before we can decide whether it extends into adult 
life. I am now watching two cases in which the affection began 
twelve and thirteen years ago, and in neither case lias the con- 
dition disappeared. I have also under my observation a young 
lady, now twenty-four years of age, in whom the process was 
first noticed when she was about five years old. The condition 
is not very common (fifteen cases in two thousand one hundred 
and ninety-seven sick children. — Parrot), but sufficiently so to 
enable every physician to see cases. A great many names have 
been employed to designate the affection : wandering rash (Ber- 
ker), ringworm, the lichenoid condition (Gubler), geographical 
tongue, and some have confounded this form of trouble with 
another psoriasis, tylosis, lichen or ichthyosis of the tongue. 
The hitter are, however, affections to be distinctly separated 
from that which has been brought into prominence by Parrot. 

The location of the disease is "almost invariably" the 
dorsum of the tongue, somewhere in front of the circumval- 
late papilla? (Butlin, "Diseases of the Tongue," p. 101). It 
begins ;it the edge or tip of the tongue in the form of a small 
patch which is characterized by a more opaque and whiter 
Color than the rest of the mucous membrane. This patch is 



110 DISEASES OF THE MOUTH (NON-SURGICAL). 

distinctly bounded by a greater or smaller part of the arc of a 
circle. The next step in the development consists in a simul- 
taneous enlargement of the outline and a shedding of the epi- 
thelium within. The outline grows, in that the thickening of 
the epithelium extends, the circular line becoming greater, 
although usually developing upon the same radii which existed 
for the original patch. This outline depends upon the same 
pathological process as the first white, opaque spot, — viz., a 
too rapid formation of the epithelial cells which have not quite 
gone through the changes to become adult epithelium. As a 
result of this, these cells are heaped upon each other in greater 
number than normal, and, as a final result, they are more 
rapidly shed. The spot now assumes the appearance of a 
white or yellowish- white boundary surrounding a red surface. 
The red surface is characterized by a glossy appearance due to 
the covering of the mucous membrane by young and translu- 
cent epithelium and an entire loss of filiform papillae. By ex- 
tension of the boundary and the simultaneous shedding of the 
epithelial layer the whole or a greater part of the tongue may 
become involved in one patch. According to Parrot the 
whole process is accomplished in from five to six days ; this, 
however, does not agree with my own observation, according 
to which the period of time varies so greatly that I would 
hesitate very much to ascribe any exact length of time for the 
development of a spot with cessation of growth. According 
to Mr. Butlin (loc.cit.), "as the circles widen out, so may they 
contract again," from which we may infer that the epithelium 
grows from the periphery towards the centre of the denuded 
spot. In the same sentence we find " but the rapidity of the 
subsidence is often so great that the surface of the tongue 
does not instantly regain its normal aspect."* The epi- 

* "As the circles widen out, so may they contract again, until each 
and every circle may disappear from the surface of the tongue ; but the 



STOMATITIS SYPHILITICA. Ill 

thelium, according to my observation, forms all over the 
denuded spot, immediately the process of extension comes to 
an end, and the rest of the process, so well described by the 
author quoted, is due to the fact that the epithelial layer is 
formed as such, and no longer as young cells never destined to 
adult development. 

Frequently two or more patches develop at the same time 
at different parts of the tongue. When this is the case one of 
them ceases to grow, while the other one seems to grow more 
rapidly, at least in the direction where they are contiguous. 
Again, it will occur that one or more new patches develop 
within an old outline; in such cases we see an undulatory, 
wavy appearance of outlines and slight elevations within the 
first boundary line. The course of the affection is that of a 
chronic disease. It may disappear for a time, so it is stated 
by all authors, but relapses are common. In the cases which 
have come under my observation the tongue is never per- 
fectly well, but there is always more or less evidence of 
this process, either in the form of an abnormal redness, the 
beginning of the development of a patch, or the presence of 
well-marked patches. I have taken occasion to watch the 
patients under my charge at times when they were otherwise 
perfectly well, but have always been able to see some change 
which would stamp the tongue as not perfectly natural. This 
disease either runs its own course and, after a greater or less 
time, leaves a normal tongue, or, as in the instances mentioned 
in the beginning, it lasts into adult life. How long into 
adult life the process may reach I am, at present, unable to 
.Mate. 

The pathological anatomy of the disease (Parrot) consists 



rapidity of the subsidence i- often so great that tin' Burfa f tin' tongue 

I instantly regain it* normal aspect; it is slightly redder and 
smoother than natural." 



112 DISEASES OF THE MOUTH (.VOX-SURGICAL.). 

simply in an irritative process or subacute inflammation, which 
goes on in the derma accompanied by the production of an 
abnormal epithelium, both quantitatively and qualitatively. 
Beyond this nothing distinctive can be obtained for this inflam- 
mation from Parrot's description, and he seems to have been the 
only one who has made microscopical examinations of tongues 
affected by this disease. The cause or causes of this affection 
are unknown to us. Parrot's view is the one which must 
occupy us here, as his reason for the syphilitic nature of the 
"wandering rash" is as follows: "J'ai pris au hazard dans 
mes notes 31 cas d'affectiou desquamative, et dans 28 les 
enfants portaient des marques incontestables de la syphilis 
hereditaire. Cela me suffit pour la caracteriser, et je dis 
qu'elle constitue elle-meme uue manifestation syphilitique, et 
que la qualification de syphilide desquamative de la lauguc, que 
je propose, est sufBsamment justifie" (p. 1 32, he. cit.). (" Hap- 
hazard, I have taken 31 cases of the desquamative affection 
from my notes, and in 28 the children showed incontestable 
signs of hereditary syphilis. This is sufficient to character- 
ize it, and I say that it of itself constitutes a syphilitic 
manifestation, and the name which I propose, desquamative 
syphilide of the tongue, is justified sufficiently.") Again, on 
the next page he states that from the 1st of January to the 
30th of April, 1881, two thousand one hundred and ninety 
seven children had entered the hospital. Of these, three hun- 
dred and twenty-eight had hereditary syphilis; out of the 
whole number of children, fifteen had the desquamative affec- 
tion, of which thirteen belonged to the class in which there 
was no doubt of syphilis, one was doubtful, and the other 
showed no evidence of lues. As a rtmme we would say that 
of the forty-six cases observed by Parrot, syphilis could be 
established by him in forty-one cases. The next thing to be 
taken into consideration is that Parrot was in the habit of 
considering manifestations as syphilitic which have not since 



STOMATITIS SYPHILITICA. 113 

been accepted as such. So that we may safely reduce the 
number forty-one somewhat. Let us grant, however, that all 
of the forty-one cases of the desquamative affection had syphi- 
lis, what reasons are given that the affection is a syphilitic 
one? None, except that the affection occurred in syphilis. 
The disease lasts an indefinite length of time it is found, 
according to Parrot himself, in patients showing no other 
manifestations of syphilis ; pathological investigations do not 
show any specific lesions; and, lastly, still according to Parrot, 
treatment has no. effect upon the disease. If we now consult 
the experience of other writers we will find that there is no 
one who can subscribe to the syphilitic origin of the " wander- 
ing rash." Parrot has then been misled by the observation of 
a coincidence into establishing the relation of cause and effect, 
and the term ''desquamative syphilide of the tongue" must be 
stricken from our list of diseases, certainly, as applied to the 
"geographic tongue" or "wandering rash." I do not think 
it would be rash to state that in the three hundred and twenty- 
eight cases of hereditary syphilis observed by Parrot a greater 
number than fifteen would have been found that had stoma- 
titis mycosa, and yet no one would think of considering thrush 
a- a syphilitic manifestation. Syphilis, then, plays no rule in 
the production of this disease; the question that arises is as 
to its etiology. As has been stated, we do not know what are 
the causes of the " wandering rash." The most commonly ac- 
cepted view that it is due to some general disturbance of health 
or to a stomachic trouble is fallacious. This will be proven by 
mtinued observation of any individual case as well as by 
therapeutic attempts. \o one ever succeeds in curing this form 
of tongue either by tonics or by diet. It is doing the patient an 
injustice to restrict bis mode of life in the vain attempt to cure 
an affection which is harmless and, as far as we know, incurable. 
There are no symptoms attached to the affection; some authors 

speak of an itching sensation, In it this certainly must he eXCep- 



114 DISEASES OF THE MOUTH (xON-SURGIOAe). 

tional. Iii the great majority of cases the diagnosis is an acci- 
dent, made when the tongue is examined for other reasons. I 
have observed four cases in which heredity seemed to play a 
role: two children in two families, the mother in one and the 
father in the other being brother and sister. The cases are, 
however, not of sufficient frequency for any one observer to 
work out any law concerning their origin. It has seemed to 
me that we are dealing with a process of epithelium formation 
which is natural to those individuals affected, and only to be 
considered abnormal in that it does not agree with the produc- 
tion of epithelium in the great majority of human beings. 
The slight changes which have been found under the micro- 
scope could be just as readily explained by considering them 
the effect and not the cause of the trouble. 

Syphilitic teeth. — The changes in teeth due to syphilis have 
received considerable attention since they were first described 
by Mr. Jonathan Hutchinson, and quite a literature has grown 
up around this one subject. The question is one which has not 
been conclusively settled, but, nevertheless, the changes which 
were originally described, and concerning which Mr. Hutchin- 
son has written so often and so well, have been accepted by so 
many as characteristic of syphilis that it will require the thor- 
ough record of a great number of well-observed cases to disestab- 
lish this view. On the other hand, a great many changes in the 
teeth have been noticed and been ascribed to syphilis which, 
certainly, are produced by a great many other causes. Thus 
Parrot (loc. cit.) divides the " odontopathie atrophique," as he 
calls it, into five kinds: the cup-shaped, the sulciformed, the 
cuspidated, the notched, and the axe-shaped. All these are, 
according to this author, distinctly due to syphilis. He admits 
that rickets may produce one or the other form, but, according 
to him, " rickets is nothing more than the last manifestation of 
syphilis upon the osseous system." Without going into details 
in the discussion of this whole subject, it has reduced itself to the 



STOMATITIS SYPHILITICA. 115 

following: Mr. Hutchinson has proven most conclusively 
that the forms of change which he has noted in his cases were 
due to syphilis. He has been enabled, by looking at what he 
considers as characteristic, to read the history of his patient, of 
his parents, and sometimes of his grandparents. Again, as a 
result of his deduction, he has been enabled to arrive at thera- 
peutic conclusions which have invariably proved the correct- 
ness of his clinical evidence. There is one important link 
missing in the chain of evidence brought forward by Mr. 
Hutchinson : no one has ever seen a lesion in the tooth-sac 
which would prove the correctness of the connection of syphi- 
lis with these peculiarly-shaped teeth. One single case, in 
which a pathological change could be attributed to syphilis, 
would establish the view most positively. It must be remem- 
bered that a great many excellent observers (Xicati, Albrecht, 
Bouchut, Gri'mfeld, etc.) do not recognize these syphilitic 
teeth as pathognomonic. Again, it must be admitted that it is 
a very simple matter to call a child syphilitic because it has 
notched incisors. It does not prove that because the child 
has notched teeth, and either or both of its parents have had 
syphilis, that the syphilis is the cause of the notched teeth. 
If this combination of circumstances is found in a great many 
cases it might be looked upon as presumptive, but by no 
means as conclusive, evidence. The subject of tuberculosis 
might be adduced as an illustration ; by the general consensus 
of professional opinion, phthisis was looked upon as an heredi- 
tary disease. No one, to-day, looks upon heredity as of any 
more value than a predisposing cause, either direct or indirect. 
Bouchut claims that any diathesis or cachexia may produce 
these peculiar teeth, and adds that he has seen cases in which 
neither parent had syphilis. ("Clinique de l'Hopital des 
Enfante Malades," p. 357, 1884.) The case that he reports, 
due to an epistaxis and followed by illness during the whole 
of infancy, seems to settle the whole question. But the great 



116 DISEASES OF THE MOUTPI (XON-SURGICAL,). 

objection, -which unfortunately can be raised in all the cases 
reported as non-confirmatory of Mr. Hutchinson, is that the 
history does not seem to have been examined as carefully as 
the subject would warrant. Bouchut's view, if correct, 
broadens the etiology, but his evidence is, if anything, weaker 
than Hutchinson's; nor can it be said that the former has 
added one iota to our conception of the whole process. It is 
possible that syphilis, like heredity in tuberculosis, is a pre- 
disposing cause for the formation of these teeth. "We know 
perfectly well that certain diseases will leave their marks upon 
the teeth, because we see that those teeth which make their 
appearance after certain illne'sses are deformed. If one lesion, 
why not another? If an erosion, why not a notch? 

Mr. Hutchinson has met this question with the answer, that 
syphilis produces only certain changes, which is eminently 
proper, but which may be overturned by subsequent observa- 
tion. On the other hand, it is exceedingly difficult, perhaps 
impossible, to prove that syphilis has produced certain well- 
defined lesions. 

The whole subject has not been conclusively settled, but 
from all indications certain lesions of the teeth must be looked 
upon as very strong evidence of the existence of hereditary 
syphilis. In the presence of these changes the patient or his 
parents would have to have a very decisive history proving 
the non-existence of syphilis to make it positive that heredi- 
tary syphilis was not at the bottom of the lesions. In the 
majority of instances, however, we have additional evidences 
which help us in our diagnosis, so that we are not frequently 
called upon to rely implicitly upon one sign. 

On account of the ready acceptance of Hutchinson's teeth 
by the profession, a great many other forms of deformed teeth 
have been described as due to hereditary syphilis. It may be 
just as well to state, in the present connection, that for these 
other forms the proof is by no means as convincing as that 



STOMATITIS SYPHILITICA. 117 

offered by Mr. Hutchinson. As will be seen, the only evi- 
dence given is that a certain author has described a certain 
form of tooth as characteristic for syphilis. "While the author 
may be a most competent observer, such a statement is abso- 
lutely valueless when it is not enforced by a careful analytical 
report of cases. 

Hutchinson's teeth. — The "test teeth" are the two upper, 
central, permanent incisors. In addition to these, however, 
there is a symmetry of deformity which is also supposed to be 
characteristic of syphilis. The " test teeth" are " dwarfed and 
notched." They are somewhat or very much smaller than 
their neighbors; they are exactly alike in shape and size, and 
are affected alike in every respect. Their size depends upon 
the intensity of the affection as well as upon the time when 
manifestations of syphilis have occurred. If a patient shows 
the manifestations of hereditary syphilis after the tenth or 
twelfth year of life it is impossible to find markings upon the 
" test teeth." It is questionable whether hereditary syphilis 
remains latent for so great a length of time; but this claim is 
made for it by authors. ("Syphilis hereditaria tarda.") The 
cause for the deformity is expressed as follows by Mr. Plutch- 
inson {London Hospital Report, II. p. 148) : "The teeth . . . 
are developed in connection with the mucous membrane; are 
parts of a dermo-skeleton. Their pulps suffer accordingly in 
an inflammation of the structure, and hence the malformations 
which are produced." If this be the case, the greater the 
inflammation the greater the deformity. 

In hereditary syphilis the two central incisors are usually 
separated from each other by an abnormally great space. The 
notch, which is characteristic, is found upon each incisor, not 
mathematically alike in each tooth, but in almost the same 
place. It. is vertical, sometimes broader at the grinding edge 
than above, and deeper, extending into the Substance of the 
tcotfa for some distance like a slit, limited at both ends by an 



118 DISEASES OF THE MOUTH (NON-SURGICAL.). 

outline whose convexity is in the same direction. Most com- 
monly it is nothing more than a semicircular notch of vary- 
ing depth. In addition to this notch, the lateral outlines of 
the teeth are decidedly convex instead of being straight. Next 
to the central incisors, the two lateral are mostly deformed ; 
they are dwarfed and have convex outlines. The canines, too, 
may be dwarfed, also equally. The rule is absolute symmetry 
of deformity, but this rule is subject to exceptions; everything 
else being equal, symmetry speaks for syphilitic deformity, 
non-symmetry, for malformations from other causes. 

Another form described by Mr. Hutchinson is the "screw- 
driver teeth." Of these he says (loc. cit.), "Among cases in which 
the teeth are peculiar without being pathognomonic, we very 
frequently meet with those in which the central incisors of the 
upper jaw are narrowed but not notched." This narrowing 
extends from the crown towards the edge, is symmetrical in 
the upper permanent incisors, and is combined with dwarfing. 
In the same article we find "some of the screw-driver teeth 
are almost as useful to the trained observer as are the notched 
ones." However, they are admitted as not pathognomonic, 
and I have certainly seen cases in which there seemed to be 
no evidence of hereditary syphilis. 

We have already quoted Parrot. Fournier makes at least 
three other forms of syphilitic teeth in addition to those of 
Parrot. From a simple loss of enamel in depressed spots to 
an absence of part of the tooth, all are alike produced by 
syphilis. Not one of the forms is characteristic for syphilis, 
but they are all probably produced by reduction of general 
health, disturbances in nutrition of the tooth while develop- 
ing, or hereditary tendencies of varied sorts. 

As far as the effect of syphilis on the time of the eruption 
of the teeth is concerned, this must vary with every individual 
case. If the syphilitic child becomes affected with rachitis, — 
and the rule that all syphilitic children become rachitic does 



STOMATITIS SYPHILITICA. 119 

not hold good in this country, — dentition will be interrupted or 
retarded. If the patient has a severe attack of infantile syphi- 
lis, the teeth will be slow in coming, just as if the general 
nutrition of the child had become affected by any other deep 
constitutional disturbance. If, on the other hand, the syph- 
ilitic invasion has been slight, teething may go on in the nor- 
mal May. I have now under my observation a child in whom 
the history has been as follows: Father syphilitic; married 
against advice. First pregnancy followed by abortion; sec- 
ond, by still-born child at term ; third, by child with papulo- 
pustular syphilis; fourth, by healthy child, developing macu- 
lar syphilide six weeks after birth. Vigorous treatment of 
father, mother, and children by mercurials. The last baby, 
now thirteen months old, has nine teeth. The whole process 
of teething has gone on in a normal way; the first two lower 
incisors appearing about the fifth month, followed in four 
months by the upper incisors. 

It is possible that the permanent teeth are affected according 
to the same rules as the deciduous ; but of this the dentists are 
better judges, as physicians are more concerned in the first than 
the second teeth. It is not unreasonable to suppose that the 
more intense the infection the better marked will be the evi- 
dences of syphilis. Yet, as far as the teeth are concerned, 
this is nut borne out by experience. Various observers state 
that, in their experience, Hutchinson's teeth have been very 
rarely observed, and some go so far as to claim that, in their 
own countries, this form of malformation is exceedingly rare. 
All authors admit the fact that very many syphilitic children 
do not have malformed teeth, and every one, I think, is able 
to verify this statement. Again, there seems to be no relation 
between the Intense forms and the appearance of this symp- 
tom; sometimes a mild case is followed by Hutchinson's 
teeth, at others a severe one. The conclusion which must be 
arrived at is that Hutchinson's teeth depend upon the inva- 



120 DISEASES OF THE MOUTH (NON-SURGICAL). 

sior: of the mouth, depending upon the intensity of local mani- 
festations, and not upon the intensity of the general affection. 

Treatment of Stomatitis Syphilitica. — This is not the place 
to speak of the general constitutional treatment of syphilis. 
As in all forms of syphilis, so in syphilis of the mouth, con- 
stitutional treatment plays a most important role. For those 
forms of stomatitis syphilitica which are apt to produce de- 
formity, or rapid destruction of tissue, that kind of general 
treatment which produces its effect in the shortest possible 
time is indicated. For those other forms which do not pro- 
duce any great amount of local damage, or which are only 
minor complications of a great general disturbance, that treat- 
ment is to be used which best fits the type of general affection. 

There is hardly any manifestation of syphilis which can be 
so readily affected by local treatment as the syphilides of the 
mouth. Again, there is no other form of syphilis which is so 
easily aggravated by local irritations. In view of the latter 
statement, prophylaxis becomes a very important factor in all 
of these cases. 

Although salivation is very rare in children, yet the careful 
physician watches the mouth when he gives mercurials to chil- 
dren. In the treatment of syphilis by long-continued use of 
mercurials, ail those prophylactic measures used against saliva- 
tion in adults should be applied to children, especially when 
there is any evidence of beginning mouth-trouble. Some of 
these ought to be used in all cases, whether mouth-trouble be 
threatened or not. If the child has teeth, they ought to be 
kept scrupulously clean, either by a tooth-brush or by other 
means. When there are no teeth, an antiseptic mouth-wash 
should be used, — sal icy late of soda, permanganate of potassium, 
listerine, or lukewarm water, which is as good as anything 
else when employed in sufficient quantities. The principle 
upon which all prophylactic measures are based is cleanliness. 
Physicians very frequently consider themselves as acting anti- 



STOMATITIS SYPHILITICA. 121 

septieally when they use a solution of one or the other anti- 
septic remedy. Combined with this there may be septic fin- 
gers, septic instruments, and gross negligence in overlooking 
those parts which require treatment most. The remedy used 
is .-imply for the purpose of easing the conscience, and when 
bad results follow, physicians are astonished, and attribute the 
results to some peculiarity of the patient instead of to them- 
selves. Absolute cleanliness is worth more than all antiseptics 
in the treatment of diseases of the mouth ; antiseptics without 
cleanliness are worse than useless. 

All irritations within the mouth must be removed. Espe- 
cial reference is made here to the teeth. If they are decayed, 
they must be attended to, either by filling or extraction ; if 
they are very sharp, they must be filed off. The latter is of 
great importance, as many a syphilitic ulcer has been kept up 
in the mouth by the constant irritation of a sharp tooth. This 
is rare in childhood, although it has been known to occur. 

The sovereign local remedy for all syphilitic ulcers, erosions, 
or losses of substance in the mouth, is nitrate of silver, applied 
in the manner described in connection with stomatitis catarrha- 
lis. Corrosive sublimate is especially indicated when there is 
very much infiltration in addition to these ulcers. It can be 
used either in dilute or concentrated solutions, and by using 
glycerin the concentration can be made very great (almost 
equal parts). The dilute solutions (0.2-1 per cent.) can be 
used with a swab to the inner surface of the mouth. If the 
child be old enough, the weakest solution can bo sparingly 
Used as a mouth-wash. In infants all the weak solutions 
ought to be applied from two to four times daily. The very 
strong solutions (as high as twelve percent.) are to be used ex- 
ternallv ; only in cases (if excoriations or rhagades that resist the 
nitrate of silver or weak corrosive sublimate solutions. These 
strong solutions are caustic in their effect, are followed by pain, 

and, not infrequently, by more or less inflammation. They 



122 DISEASES OF THE MOUTH (NON-SURGICAL). 

must be handled very cautiously ; their indication is very lim- 
ited, and they need not be applied oftener than two or three 
times. Where children are old enough, emplastrum hydrar- 
gyri, softened with lanolin, frequently gives better results 
than anything else in syphilitic cracks of the corners of the 
mouth. The best mouth-wash, in syphilitic cases, is a solution 
of chlorate of potassium. There is no remedy which counter- 
acts the tendency to stomatitis mercurial is better than this, and 
none which acts more promptly, as has already been pointed 
out in connection with stomatitis ulcerosa. It sometimes be- 
comes necessary to use an astringent as a local remedy. Any 
substance containing tannic acid will fulfil the indication per- 
fectly; either tannin itself — although objectionable in young 
children on account of its taste — or tinctura ratanhiae, tinctura 
catechu, — the latter being least objectionable.' 

STOMATITIS PRODUCED BY LEPTOTHRIX BUCCALIS. 

This is an extremely rare affliction in children. From the in- 
vestigations of Miller ("The Micro-Organ isms of the Mouth," 
1890) we are led to the conclusion that leptothrix is not a 
pathogenic organism. He has described at least four varieties, 
all of them uncultivatable and of uuknown pathogenesis. His 
position, and undoubtedly the true one under present condi- 
tions, is " morphologically as well as physiologically considered, 
leptothrix buccalis has been regarded as a veritable wonder. 
It has been said to perforate and split up teeth, its elements 
to cause all kinds of diseases in the oral cavity, to penetrate 
into the lungs, the stomach, and other parts of the body, and 
everywhere to manifest a destructive influence. As absolutely 
nothing was known concerning the biology and pathogenesis 
of this organism, all sorts of wonderful properties were ascribed 
to it. It is, therefore, high time to banish this confusing name 
from bacteriological writings." 

Clinically speaking, a lower form of life that has been called 



STOMATITIS SYPHILITICA. 123 

leptothrix forms membranes within the mouth, about the teeth, 
the eircumvallate papillae of the tongue, and especially upon 
the tonsils. These membranes are all characterized by their 
dark, grayish-black color and their firm adherence to the soil 
upon which they grow. These evidences are sufficient, as a 
rule, to establish a diagnosis ; an examination under the micro- 
scope will show the absence of saccharomyces albicans, or any 
of its organs, and the differential diagnosis will, therefore, 
be very simple. The symptoms that are produced are very 
slight, and this may account for the great rarity of the disease 
in children. It is only when the membrane appears upon the 
tonsils that adults complain, and in my own experience a case 
of stomatitis leptotrichia has never occurred in children. 



124 DISEASES OF THE MOUTH (NON-SURGICAL). 

VIII. 

DENTITION. 

No subject in pediatrics possesses so large and varied a liter- 
ature as that of teething. Upon no subject do we find more 
diversity of opinion than upon teething. It is, therefore, very 
natural that great importance should be attached to its discus- 
sion, which ought to be carried on in a thoroughly objective 
manner. The latter, unfortunately, is an exceedingly difficult 
matter, for more than one reason. Nearly all the medical 
superstitions of childhood pertain to teething. Social position, 
education, culture, do not seem to eradicate them; a string of 
amber beads, a mouse's tooth, or a bag containing some odor- 
iferous compound may be found in the mansion as well as the 
tenement-house. It is not an easy matter for the physician 
to stand by patiently and have his skill counteracted by an 
amulet. Moreover, the idea of the causation of disease by 
teething has taken such deep roots in the minds of people that 
diseases easy of treatment end fatally because they are either 
overlooked or attributed to the process of teething. It is not 
difficult to answer the question, " Who is to blame ?" If a 
cursory glance be taken at the literature of the subject, authors 
will be found — and good ones, too, both old and modern — 
who do not hesitate to ascribe any form of disease to teething. 
The more improbable the connection between teeth and dis- 
ease, the more delight does the average author find in stating 
that the affection is due to teething ; or, if he be of a specu- 
lative turn of mind, the more ingenious will be his method of 
tracing cause and effect. It would be an interesting though 
useless task to collect all the diseases that have been evolved 
from teething. Then there are those who, writing for and 
not from experience, copy what has been said by others, ac- 
cepting facts badly collected and not thoroughly verified; 



DENTITION. 125 

these are the ones that go to make up the number who assist' 
in the errors that are being made daily, for they are authors, 
and an author is supposed to be an authority. Hebra, the 
great dermatologist, who detested rushing into print, would 
say to the person who entertained a new view concerning 
eczema, " When you have seen ten thousand cases of eczema 
come and talk to me." It is not necessary to have seen ten 
thousand children teething, — in fact, not one-fifth the number; 
but it would be conducive to the welfare of humanity if phy- 
sicians would take the trouble to observe teething children 
more and believe less in what has been written on the subject. 
Almost daily do we see errors in diagnosis occur because of 
the doctrines that have been and are being taught on the sub- 
ject of teething. This statement can be substantiated by any 
number of cases in the experience of the observing physician. 

It is but natural to ask for patience and quiet, impartial 
judgment in the discussion of this subject, when one sees the 
errors that are committed as the result of this kind of teach- 
ing. Within a short space of time I have seen the gums 
lanced in children suffering from pneumonia, measles, and 
tubercular meningitis; in each case the diagnosis of teething 
had been made, in each case the child died, and in each case 
both the physician as well as the surroundings were settled at 
the bedside with the stoicism of followers of Mohammed. 

We deal with two processes : one, normal dentition, which 
is admitted to exist even by the most rabid adherents of the 
teething doctrine (only in about twenty per cent, of all chil- 
dren, however); the other, abnormal dentition, or dentitio 
(Jijjicilis. Before going on to the further description of the 
two processes, it will be both interesting and profitable to look 
into the history of the subject. 

The late \j. Fleipchmann, of Vicuna, published a small 
volume in 1*77 (" Klinik d. Pediatrik"), in which a complete 

history of the subject will be found, and from which the fol- 



126 DISEASES OF THE MOUTH (NON-SURGICAL). 

lowing abstract is made in part. Fleischmann was one of the 
most thorough authors who has ever written upon pediatrics, 
and his early death left a great void in the ranks of active 
workers in diseases of children. 

We again begin with Hippocrates (400 B.C.). In the apoc- 
ryphal work " De Dentione," we find that children teethe 
more easily when they have loose bowels, and better in winter 
than in summer; that those having a cough teethe late and 
lose flesh. In his " Aphorisms," which are considered genu- 
ine (Sect, iii.), the statement is made that teething children 
suffer with itching of the gums, fever, convulsions, and diar- 
rhoea, especially when the eye-teeth come through. Fat chil- 
dren and those that have a tendency to constipation suffer 
most. He knew that the teeth are formed during foetal life, 
and advised that the children be allowed to bite upon hard 
substances during teething. 

Aristotle (384-322 B.C.) had erroneous notions concerning 
teeth : that men have more teeth than women ; that the teeth 
continue to grow during the whole lifetime of the individual, 
and that repeated teething occurs in strong people. 

Galen (131-203 A.D.) tells us that the teeth act as foreign 
bodies during eruption, and that they produce all possible bad 
svmptoms, because they cannot be encapsulated like foreign 
bodies. Some of his pupils believed the most wonderful 
things: the gums should be rubbed with dog's milk, or with 
the brain of a rabbit, in order to cause the teeth to come 
through more rapidly ; here, too, we find the first mention of 
an amulet's power against the pains of teething, " Yeteris 
cochke cornu pellicula illigatum pro amuleto appende." The 
first tooth was considered an epiphysis of the permanent tooth 
in order to explain Aristotle's erroneous notions. Oribasius 
(326-403 A.D.), an indirect follower of Galen, prefers Cyprian 
butter, or oil of lilies, to the brain of a rabbit. 

Aetius, at last, developed the whole subject of diseases of 



DENTITION. 127 

dentition. Irritation from the tooth produces inflammation 
which may extend to the ear, the nose, the eyes, the stomach, 
may produce fever, etc. The child must not be allowed to 
become constipated, otherwise the inflammation will extend 
upward. Oil must be used to rub the gums, but hard sub- 
stances must not be given to the child to bite upon, as they 
harden the gums ; amulets {e.g., the tooth of a viper encased 
in silver) are of great value. 

Paul of iEgina (G25-690) states that couvulsions are apt to 
occur during teething : these he counteracts by washing the child 
with a decoction of heliotrope; he cures diarrhoea by placing 
a spice-bag with rose-seeds upon the bowels (it is pleasant to 
meet some of our old friends twelve hundred years back) ; the 
itching of the gums is diminished by the use of old herrings. 

Rhazes (860-932), in his work " De ^gritudinibus Puero- 
rnm," writes as follows : " Promotion is easy and is accom- 
panied by little pain when the teeth come through rapidly, but 
they are not strong, and, vice versa, when they grow slowly the 
pain is greater but the teeth are stronger." Teething is easier 
in spring than in winter; in summer teething is painless, but 
abscesses of the cheeks and gums, as well as itching of the ears, 
are more common ; hemorrhages, fever, diarrhoea, or constipation 
may also be present. He makes no mention of convulsions. 

Avicenna adds nothing original to the work of his prede- 
cessors. 

Vesalius (1514-1564) was the first to practise incision of 
the gum iii case of a wisdom-tooth. 

Eustachius was the first to controvert the views of Aristotle, 
Galen, and Vesalius, and to verify the statement of Hippoc- 
rates, — i.e. 3 that the teeth are already formed in the foetus. 
Ilr also opposes the view that the eye-teeth have anything to 
do with the eyes. 

Ambroise Pare* (1510-1599) first advised lancing of the 
gams in difficult teething. He reports that those teeth that 



12S DISEASES OF THE MOUTH (NON-SURGICAL). 

had been lanced in a child dying from difficult teething came 
through even after the death of the child. 

After this period the most curious theories are to be found 
in the literature of teething. Scarification is almost universally 
recommended; amulets increase in number, and are divided 
into classes according to their supposed strength. 

This sort of medication continues through the seventeenth 
century; in the eighteenth century the amulets are dispensed 
with ; but the number of diseases and symptoms due to teeth- 
ing is gradually increasing. John Hunter (1772, — The Works 
of J. Hunter, 1835) gives the following list : " Diarrhoea, cos- 
tiveness, loss of appetite, eruptions on the skin, especially on 
the face and scalp, cough, shortness of breath, with a kind of 
convulsed respiration, and similar to that observed in whoop- 
ing-cough, spasms of particular parts, either by intervals or 
continued, an increased, and sometimes decreased, secretion of 
urine, a discharge of matter from the penis, with difficulty in 
micturition, resembling symptoms of gonorrhoea in its violent 
form. The lymphatic glands are apt to swell at this time; if 
the child has a strong tendency to scrofula, this irritation will 
promote the disease. There may be many other symptoms 
with which we are not at all acquainted, the patients, in gen- 
eral, not being able to express their feelings." For treatment, 
cutting the gums is " the only method of cure." " It often 
happens, particularly when the operation is performed early in 
the disease, that the gum will reunite over the teeth ; in which 
case the same symptoms will be produced, and they must be 
removed by the same method." He has lanced the same teeth 
ten times, giving relief each time, but followed by a relapse. 

Jacob Plenk (1779) adds the following list to those diseases 
already mentioned : Gutta rosacea, deafness, amaurosis, swell- 
ing of the knees, paralysis, and lameness in one or both legs, 
suppuration, and dry gangrene. 

Rosen von Rosenstein not onlv believes that any ill can 



DENTITION. 1 29 

result from teething, but thinks that every child ought to be 
prepared for teething as soon as it reaches the age of three 
months; the gums should be rubbed with the finger, e very- 
day in order that they may become thin enough for the teeth 
to come through without giving pain. If this has not been 
done, he recommends one of a thousand and one remedies to 
soften the gum as well as giving relief to pain by means of 
venesection, leeches, and scarification. 

Girtanner (1796) adds a few more diseases to the long list, — 
increase in the flow of bile, nausea, stomach cramps, fainting, 
and epilepsy. 

Armstrong (1786) is the first who dares to lift up his voice 
against the views that have been expressed. He does not believe 
that all cases dying about the time of dentition die from teeth- 
ing, and warns against the too free use of the gum lancet, having 
seen the scarification of the gums followed by fatal issues. 

Beginning with this, we first find Wichmann (1800) op- 
posing the views expressed by the older authors with great 
firmness and with all the logic and force that followed the 
knowledge of physiology. He ends his long article as follows : 
"It is to be hoped that, in the future, dentition will be called 
up only when it would be impossible to comfort the relatives 
with the impotence to designate the true nature of the disease 
or to quickly calm the laity." 

From this time the two opposing camps have been formed: 
in the one, flio.se believing in the possibility of production of 
all kinds of disease by teething; in the other, those believing 
in the production of teeth, and teeth only, with occasional bad 
symptoms by this same process. On both sides there are 
champions worthy of the cause: Barthez and Rilliet, West, 
Bednar, Steiner, Vogel, and a great many others, for the dis- 
eases produced by dentition; Politzer, Bouchut, Fleischmaun, 

and, in our < ntry, Jacobi especially, against this view. 

Jacobi has done more than any s, probably, to place the 

y 



130 DISEASES OF THE MOUTH (NON-SURGICAL). 

whole subject of dentition upon its proper level (1862); and 
the thoroughness and analytical acumen displayed by him in 
his argument are such that it requires but close following to be 
thoroughly convinced of the truth of his deductions. In order 
to be able to make deductions, it is necessary to take a cursory 
view of the whole process of teething as it goes on normally. 
It will be readily understood that a detailed description, histo- 
logical and biological, would be entirely out of place here; it 
is our object to view the conditions from the aspect of topo- 
graphical anatomy, so that reference to it can be had in the 
following discussion. 

The statement that the greater part of the process of teeth- 
ing is accomplished before the child is born will, I hope, be 
thoroughly verified by what follows. About the seventh 
week of intra-uterine life a ridge is formed within the mouth, 
caused by a thickening of the oral epithelium, and at the same 
time a dipping down of this same epithelium into the embryonic 
tissue which goes to make up the jaw. The epithelium which 
dips down is called the enamel germ ; by growth and extension 
it shortly becomes converted into a flask-shaped outline, rest- 
ing upon the embryonic tissue and lining a cavity. Partitions 
are formed in this continuous, irregularly-shaped depression, 
so that there are differentiated ten small bodies in each jaw. 
At the same time a papilla forms from below which grows 
upward, and, in a short time, develops to form a complete 
mould for the enamel germ which comes to rest upon it, and 
forms its lateral and upper boundaries. This papilla is highly 
vascular, and is called the dentine germ. While this is going 
on the connective tissue around the primitive tooth differenti- 
ates itself to form an investing membrane for the tooth, called 
the dental sac. Osseous tissue is being formed all the time in 
the partitions between the primitive teeth, and finally Ave have 
the alveolus formed around the tooth-sac, "at first with wide 
openings which afterwards are narrowed, but so as to allow 



DENTITION, 131 

the contained sacs to cohere with the gum along the border of 
the jaw" (Schaefer). We have now arrived at the time of 
birth, and it will be necessary to see what has become of the 
various tissues we have seen developing. The enamel germ, 
with its two layers, forms the internal lining of the dental sac 
and the enamel itself. The dentine germ has formed the dentine, 
the pulp-cavity of the tooth, and the beginnings of the fangs. 
The dental sac, enclosing the tooth, has itself two layers, an 
outer vascular connective-tissue layer and the inner one, part 
of the enamel organ, going to form the so-called cuticula. 
The alveolus has been formed by bony deposit with its open- 
ing quite wide (Fleischmann), wider than is necessary for the 
crown of the tooth to pass through. As far as the develop- 
ment of the whole jaw is concerned, this must be looked upon 
as disproportionately great for the small number of teeth, so 
that there is more than enough room for all the tooth-sacs and 
no crowding, the one upon the other. The permanent teeth 
are formed, practically, in the same manner as the temporary, 
except that there the enamel germ is formed from the enamel 
germ of the temporary teeth, in the shape of a small sac 
which goes to it- development in the same way as it did in the 
temporary tooth. 

At the time of birth, then, we would have an individual 
tooth — let us take the lower central incisor — with the following 
topographical relations : Above, we find the tooth-sac, the sub- 
mucous connective tissue, and the mucous membrane ; on 
either side we find the tooth-sac and bony substance. The 
tissues which interest us most are those that separate the tooth 
from the oral cavity. The tooth-sac is very thin, and offers 
very little resistance to the upward or downward growing 
tooth; the same can be said for the mucous membrane. The 

.submucous connective tissue is comparatively thick, and is (he 

only substance that can be talon into consideration as opposing 
the developing tenth, as the alveolar cavity has been shown to 



132 DISEASES OF THE MOUTH (nOX-SURGICAL). 

have a sufficiently large outlet. The force that causes the 
teeth to come through the gums is the calcification of the 
fangs. As a result of this calcification the tooth is elongated, 
and, enclosed as it is, room has to he made for this elongation. 
It is not surprising to find that the tooth is forced in the 
direction of least resistance, and, being everywhere surrounded 
by cartilaginous and bony tissue except in the direction of the 
mouth, it naturally begins to move in this direction. We 
have seen, furthermore, that the resisting medium is the sub- 
mucous connective tissue. Let us go on and find how this 
resistance is overcome. 

The force at work is long-continued slight pressure, and 
this causes atrophy of the mucous membrane. This begins to 
work at different periods, depending upon the development of 
the teeth; at birth it begins in the lower incisors, shortly after 
in the upper incisors, so that with the completion of the third 
month of life the molars are already beginning to have their 
roots calcified (Pierce, " American System of Dentistry"). The 
question, "When does dentition begin?" must be answered by 
"at birth," provided we are satisfied with considering the be- 
ginning of dentition as applied to the beginning of pressure 
upon the soft tissues. This, as will be seen, is perfectly logi- 
cal, as nearly all the symptoms attributed to teething are sup- 
posed to be due to pressure. On account of the innumerable 
symptoms that have been pointed out it is impossible to state 
when teething does begin; it is not uncommon to find the 
eruption of teeth within a few days prophesied by wise per- 
sons who rely upon certain symptoms, and the teeth not forth- 
coming within as many months. It becomes a question then, 
When does teething begin? when the teeth begin to break 
through into the soft tissues, as answered above, or when the 
teeth make their appearance in the mouth? The latter is the 
one that can be used to greatest advantage for more reasons 
than one, not the least important being that the time between 



DENTITION. 1 33 

the appearance of the first and last teeth is longer and that we 
have some visual testimony of the process. It must be added, 
however, that very few would be willing to place the beginning 
of teething at the time of the appearance of the teeth, and, to 
a limited extent, they are correct, as certain symptoms fre- 
quently precede the eruption of a tooth ; these are so illy 
defined, so varied, and the time of their manifestation is so 
various, that no reliance can be placed upon them. 

I have collected a list of modern authors in tabular form 
in order to show how widely they differ on the subject of 
normal teething, and to bring out another point which will be 
discussed hereafter. It is a strange commentary upon the ex- 
istence of accurate knowledge that the views of authors differ 
so widely upon a subject so common as teething. It has caused 
not a little difficulty to arrange these views under the three 
headings that follow, and a close examination of the tables will 
show that some of the authors quoted cannot, strictly speaking, 
be brought into a class with any others but themselves. In 
this connection, it would be useless to examine into the causes 
of this diversity of opinion. Not the least important factor, 
however, is that most physicians have received their first in- 
formation on the subject from the anatomists. The anatomists, 
however, would manifestly be the last persons to go to for 
information regarding a process that goes on in childhood, 
their observation being confined almost exclusively to the 
adult. J n witness to the truth of this statement it is only 
necessary to recall the fact that anatomical research, as applied 
to infancy and childhood, is only beginning. Furthermore, 
where the anatomists have examined into this question, — and 
sonic of them have done it extremely well, — they have had 
for materia] children who died of some disease that has prob- 
ably affected the time of the appearance of the teeth. Again, 
it Lb certainly necessary, in order to arrive at proper conclu- 
sions in regard to a physiological process, to examine into it 

while it is going on, and that is during life. Results obtained 



134 DISEASES OF THE MOUTH (XOX -SURGICAL). 

in any other way must, of necessity, be erroneous. The list 
is far from complete or exhaustive, but will, I think, illustrate 
what is to be shown. Three orders of appearance have been 
put down for normal teething: 1. The appearance of the teeth 
in pairs, — i.e, as far as the incisors are concerned. 2. The ap- 
pearance of the first two incisors, then all the others, and 
then the molars. 3. The appearance of the first lower in- 
cisor, then the four upper incisors, then the first molars, and 
with them the last lower incisor. 

The first teeth are put down, by most authors, as being the 
two lower central incisors, although a goodly number of 
authors will be found that believe in the proruption of the 
lateral incisors as the first. My own impression is that, in the 
great majority of cases, the third method of teething is the 
normal one. The authors who claim that normal teething 
goes on in the first manner described above are as follows : 



£.1 

5 a 


fej 




E 

u p 


£ 1 


1 


05 * 




o — 

s 2 




-3 

* c 

E- 1 S 


c — 

3 


5 2. 

C *=i 


1" 




6-7 i 4-6 


4-6 


4-6 






End of 


Hyrtl, 1873. 


mouths.; weeks. + 


weeks. + 


weeks. + 






2d .\ ear. 




7 


4-6 


4-6 


12-14 


16-20 


20-30 


Tanner and 


months, weeks. + 


weeks. + : weeks. + 


months. 


months. 


months. 


Meadows, 1871. 


7-8 


2 


4-6 4-6 


12-14 


3-4 


24-30 


Day, 1881. 


months. 


weeks. -f- 


weeks. + weeks. + 


months. 


mouths. + 


months. 




3-10 


9-16 


13-17 


13-17 


16-21 


16-25 


23-36 JBagiusky,1887. 


months. 


months. 


mouths. 


months. 


months. 


mouths. 


mouths. 


6-12 




10 


11 


12-16 


17-20 


20-24 Fleischmann, 


months. 




months. 


months. 


months. 


months. 


months. 1S77. 


7 


6 weeks-2 


In a short In a short 


3-4 


3-4 


24-30 West, 1874. 


months. 


months. + 


time.-t- 


time.+ 


mouths. + 


months. + 


months. 




7-0 








12 


16-20 


Second 


Eustace Smith, 


months. 








months. 


months. 


year. 


1884. 


6-7 


At end of 


At end of At end of 


12-16 


16-24 


24-30 


J. Lewis Smith, 


months. 


12 months. 


12 months. Vi months. 


months. 


months. 


mouths. 


1881. 


7-0 


Several 


End of 


16-18 


18-20 


20-24 Henoch. 


months 


weeks. -+- 


\ first year. 


months. 


mouths. 


mouths. 



DENTITION. 



135 



Those who claim that normal teething goes on in the second 
manner are as follows : 



Two lower 
Lateral 

ludsors. 



Six 
Incisors. 



Four First 
Molars. 



Four 
Second 
Molars. 



6-9 2 weeks-3 

months. mouths. + 

5-8 . 7-10 months 

months. , (4 lateral.) 
(4 ceutral.) 

6-7 7-9 

months. mouths. 



First half 
2d year. 



12-16 

mouths. 



Second half Third year. Schnitzer and Wolf, 
2d year, j 1849. 



Beginning ! End of 
of 2d year. Second year. 



Henke, 1830. 



To which may he added Mefssner (1844), who makes teething hefdn at seven months and 
enrl with th« second year of life, and Wendt (1836), beginning with the 20th-28th week 
after birth and ending the middle of the second year. 



Authors who believe the third method to be the rule are 
follows : 



Two lower 
Central 
Incisors. 


Four 

Upper 

Incisors. 


Four First 
Molars and 

two lower 
Lateral 

Incisors. 


Four 
Canines. 


Four 
Second 
Molars. 




4-7 

mouths. 


8-10 
mouths. 


12-14 
months. 


18-20 

months. 


28-34 

months. 


Gerhardt, 1874. 


4-7 
mouths. 


8-10 
mouths. 


12-16 

months. 


18-24 
months. 


20-30 
months. 


Starr, 188G. 


5-7 
months. 


8-10 
mouths. 


12-15 
months. 


18-24 
mouths. 


30-36 
mouths. 


Ililttenhrenner, 1888. 


4-7 
months. 


8-10 
months. 


12-16 
months. 


18-24 
months. 


20-30 
months. 


Vogel, 1874. 


7-9 
months. 


8-10 

months. 


12-15 
months. 


18-20 
months. 


20-30 
mouths. 


.Tacobi, 1887. 


6-8 

months. 


- 10 
months. 


12-14 
months. 


16-20 

muiitliH. 


20-36 
months. 


Doming, 1889. 


2-15 
months. 


11-12 

months. 


17-18 
months. 


2 years. 


30 months. 


BarthezandRllliet,1861. 



A^ has been Been by these tables, a wide difference exists, 
not only as to the oidcr of dentition, but also as to the times 
of the eruption of the different groups. The earliest time 



136 DISEASES OF THE MOUTH (^OX-SURGICAL). 

given for the appearance of the first tooth is two months, the 
latest, fifteen months, although the same authors (Barthez and 
Rilliet) state that normal teething may begin at any time 
during the first two years of life. The termination of teeth- 
ing is put down, at its earliest, at eighteen months, and at its 
latest at thirty-six months ; concerning the latter dates there 
seems to be more uniformity of opinion than concerning the 
beginning of dentition. 

The questions to be discussed are : AVho is right among 
these observers? and how are these observations, apparently 
irreconcilable, to be explained ? 

A great many authors have put down the two limits instead 
of the average time of their observations, so that we can 
readily understand the statements of Barthez and Rilliet. 
Again, the time of eruption of the first teeth depends entirely 
upon certain conditions of the child and its surroundings. 
Nationality, therefore heredity, plays a most important role: 
French children teethe early; English, Russian, German, and 
Italian children one to two months later on an average, and 
Hungarian children still later. In this country, on account 
of the presence of so many nationalities and their mixture, we 
naturally find that the average time of teething depends 
largely upon the material taken for the calculation. It is my 
own impression that the average child has its first two teeth 
with the completion of the seventh month, and this seems to 
accord with the statements of most American authors (Jacobi, 
Doming, J. Lewis Smith), Starr alone having retained the 
four to seven months for the first two teeth, as put down by 
Vogel and Gerhardt, which must surely represent exceptions 
and not the rule. 

It is stated that climate has an effect upon the time of 
teething (Fleischmann), and this can be accepted, as the ex- 
planation would be found in the effect of climate upon the 
general constitution. The latter, after all, is the predomi- 



DENTITION. 1 37 

nating cause for the early or late eruption of teeth, everything 
else being equal. This has been proven very frequently, 
although, possibly, in a given individual case it may not be 
true. The development of the teeth goes on equally with the 
general development ; a child well developed for its age will 
usually have its teeth early and regularly, and the converse of 
this holds true. 

There are certain diseases which retard the eruption of 
teeth ; but beyond this, there are children that teethe late with- 
out any appreciable cause. It is going too far to state, as 
Rehn does, that every case of delayed dentition is due to 
rickets. The observation is frequently made, and I am pre- 
pared to verity it fully, that there are certain families whose 
children teethe late, and yet these children are in good condi- 
tion in every respect. The time of eruption depends for its 
physical basis upon : first, the distance that the tooth has to go 
through from the dental sac to the mouth; secondly, the 
time when the calcification of the fang begins ; and, thirdly, the 
condition of the organs from which the tooth develops. If 
the distance be great, it can be overbalanced by an early and 
great deposit of calcareous matter in the tooth ; a tooth which 
is quite superficial might be long in coming through if the 
deposit is not sufficiently early or great. Lack of develop- 
ment in the rudimentary organs could be compensated for, 
partly, by an early and great calcification; but it is manifest 
that this could only be to a certain degree, and in some 
instances do compensation could take place in any manner. 
Now, the deposit of calcareous matter is a process depending 
mainly upon a proper supply of raw material in proper 
form, and this, again, is due principally to general causes, 
and nnt to those acting in a purely local way. There 
arc those effects upon the embryonic structures which are 
never overcome (syphilis); again, there are those which leave 
structural changes (diseases of the foetus); and, finally, those 



138 DISEASES OF THE MOUTH (NON-SURGICAL). 

that produce a great retardation of eruption (rickets, fevers 
during infancy, etc.). 

As far as the order of eruption is concerned, it is not diffi- 
cult to reconcile the various methods that have been described. 
The fact remains that, as in the case of normal labor, we 
must make a compromise in order to state which is the normal 
method of teething. This can be done only, as it has been 
done in obstetrics, by a carefully-conducted statistical research, 
which shall include a great number of cases. In this way we 
would be able to establish one way of normal teething instead 
of the three put down by authors. As it is, we must admit that 
normal dentition may go on in any one of the three ways, and 
that the differing views mean only that one author has observed 
his way most frequently. It certainly seems strange that we 
still find authors, including one on dentistry, who find the 
canine teeth appearing before the molars, and it is very diffi- 
cult to explain these statements, if we consider them based 
upon observation on the part of the authors themselves. 

It is more than likely that the latter is not the case. The 
mistake, on the part of a dentist, is more than excusable, as 
dentists have their principal dealings with adults. It is cer- 
tainly gratifying to know that those dentists who are abreast 
with the times give as much attention to the teeth of children 
as to those of adults. 

The reason why certain teeth appear before others depends 
upon the explanation given before. The more perfect the 
embryonic structures, the nearer the surface of the mouth, and 
the smaller the tooth, the sooner will it come to the surface. 
These are the factors that cause the incisors to appear first, to 
be followed by the molars, and then by the canines. In the 
latter, it is the calcification of the fang that causes its late ap- 
pearance ; it is not due to some far-fetched metaphysical reason, 
as claimed by some authors, but simply a question of lime-salts. 

We must look to the same causes for premature dentition as 
we do for normal dentition. It is a well-recognized fact that, 



DENTITION. 139 

occasionally, children are born with one or more teeth, and 
the omens that have been attached to this, or to the appearance 
of teeth before the fifth or sixth month of life, are numerous. 
Some claim that it is a favorable sign of longevity, strength, 
good teeth, etc. ; others claim the opposite. These cases occur 
in the experience of nearly every practitioner, and their im- 
portance has been magnified, not so much by physicians as by 
historians, especially by those who have studied their history 
from the stand-point of predestination. Premature teeth can 
be divided into three classes, each of which is due to some 
alteration in the action of one of the fundamental causes for 
the eruption of teeth. Changes in the embryonic structures 
produce teeth without fangs that hang more or less loosely, 
and are attached by a strip of mucous membrane only. An un- 
naturally small amount of covering to a tooth will cause it to 
appear long before its time, and, finally, too great or too early 
deposit of calcareous material will produce the same result. 
It occurs, sometimes, that more than twenty primitive teeth 
are formed, and then one or more may be found prematurely 
in the mouth. Primitive teeth, produced as the result of the 
first two causes, are, as far as we know, of no prognostic 
significance. Those due to premature calcification are said 
to denote premature ossification of the bones of the head. 
K Afl a general rule, however, premature appearance of the 
teeth is connected with premature ossification of the bony 
System in general, and of the fontanels and sutures of the 
cranium in particular. When this is the case, the upper in- 
cisors, as a rule, appear first, undoubtedly in connection with 
the fact of the premature ossification of the upper part of the 
cranium. This is a serious occurrence. When premature 
ossification is congenital, it makes parturition difficult and 
renders the child idiotic or epileptic." (Jacobi, "The [ntesti- 
nal Diseases of Infancy and Childhood," pp. 102-103, 1887.) 
While all this may occur, and undoubtedly lias occurred, yet, 



140 DISEASES OF THE MOUTH (NONSURGICAL). 

according to my own observation, it must be the exception. 
If any change about the head of a child with premature teeth 
is to be noticed, it is just as apt to be in the direction of 
hydrocephalus as the opposite; therefore large fontanels and 
diastatic sutures. It is now over fifteen years since Jacobi 
first called my attention to this combination of irregular 
teething and idiocy. Since that time I have examined into 
the history of every child whose two upper incisors came 
through first, and also into the relation of the teeth in idiots 
with premature synostosis. The latter instances are com- 
paratively rare, but in not a single instance could the mother 
be positive that the upper teeth appeared first. In several 
large-headed idiots, or, rather, idiots with widely-open fon- 
tanels and diastatic sutures, I have been able to elicit the 
fact that the upper teeth had appeared first, but not in a 
sufficient number of cases to establish any law. It has 
always seemed to me to be purely a coincidence. As I have 
not kept record of these cases, — it being almost impossible 
to do so, — my statements, as opposed to those of so reliable an 
observer as Jacobi, must go on record for what they are worth, 
to be verified or overthrown by future records. 

The question of what is to be done with these premature 
teeth is one that is deserving of close attention. It will not 
do to put down the absolute rule that all premature teeth must 
be pulled. There are positive indications when one of these 
teeth should be extracted. When the tooth dangles in the 
mouth attached only by mucous membrane, there can be no 
hesitation about severing its connection and getting rid of a 
foreign body that is absolutely useless. When these teeth are 
tightly set in the mouth, it always becomes a question what to 
do with them. The rule can be made that they are to be let 
alone unless some special indication exists for their extraction. 
I cannot agree with Fleischmann when he says that "the 
supposition that children who have teeth can hurt the nipples 



DENTITION. 141 

of their mothers can hardly be taken seriously" (Joe. clt, p. 
78). There is no doubt that children with teeth do hurt the 
nipples in more than one way, and that they do not cover their 
teeth with the lips, as Fleischmann believes. It is true that, 
in nursing, the two lower teeth are covered by the tongue, 
but as soon as the upper incisors appear the baby begins to 
bite at the nipple, and, with women whose nipples are not 
perfectly normal or thoroughly protected, it is only necessary 
to see where the fissures are formed in order to convince one- 
self how these cracks were produced. But, in addition to 
this, these premature teeth are sometimes situated in such 
locations as to render all attempts at nursing painful and 
occasionally futile. When it comes to a question, then, of ex- 
tracting a tooth or jeopardizing the life of an infant, or even 
its thriving, the way is perfectly clear, and there can be no 
possible difference of opinion as to the course to be pursued. 
The following two reasons are the principal ones for saving 
these tilth : first, we are never perfectly sure that we are not 
producing a loss which will not be repaired until the seventh 
or eighth year of life. The premature tooth that has been 
extracted may be the only temporary incisor that the child 
will have, and no tooth will be formed until the permanent 
incisor makes its appearance; secondly, children with prema- 
ture ti.th may be puny and delicate, perhaps syphilitic; in 
such children, hemorrhages follow the slightest disturbance of 
continuity of tissue, and several cases are on record in which 
children havelosl their lives by the extraction of these premature 
teeth. Magitot, who lost a child after extracting two prema- 
ture incisor teeth [Gaz. dea HSpitaux, 1876), puts down the 
rule never to extract these teeth, as the result of his unpleasant 
experience. 

Rickets is the mosi common cause of delayed dentition. 
lint, as has been pointed oul before, not every child that gets 
it- teeth late has pickets. The effects of rachitis upon the 



142 DISEASES OF THE MOUTH (.VOX-SURGICAL). 

teeth are many or none at all, depending upon the amount of 
rachitic changes that takes place in the bones of the jaw. If, 
as occurs not infrequently, the bones of the head are not at all 
attacked by the rachitic process, we can certainly not expect 
any lesions about the teeth. In such cases, rachitis may de- 
velop after the time when the first six or even first twelve 
teeth have made their appearance, and then there will be, 
practically, no delayed dentition. An attack of rickets com- 
ing on at so late a time may delay the eruption of the follow- 
ing teeth, but, manifestly, this is accomplished by constitutional 
derangement only, and not by any local effect. But rickets is 
by no means the only cause that produces late teething. Any 
disease producing a disturbance followed by diminution of 
nutritive supply to the teeth will result in a late eruption of 
the teeth, provided all the other factors for dentition are 
present in normal quantity. As such we must reckon all dis- 
turbances accompanied by long-continued fevers, all long-con- 
tinued diarrhoeas, all so-called cachexias. It will frequently 
be seen that one or more teeth come through during an attack 
of scarlatina, typhoid fever, etc., and this does not militate 
against the view just expressed. If this patient be kept 
under observation for some time, the next group of teeth will 
be found late in their appearance, and, possibly, deformed. 

A more common cause for this late eruption of teeth is to 
be found in heredity. In another place I have recorded three 
generations of people ; the first of these was decidedly rachitic ; 
square head, bow-legs, etc. ; the second, with the same bony 
malformations to a less degree; and the third, with the char- 
acteristic square head without ever having had any symptoms 
of rachitis. This is, what seemed to me, a well-marked ex- 
ample of the law of heredity. In the same way we can 
imagine late teething set up in a family, by some affection, 
perhaps, that has acted through several generations, and re- 
sulting, ultimately, in a hereditary tendency. Early or late 



DENTITION. 143 

teetli are just as distinctive of families as are good or bad 
ones. 

Defective food -supply (i.e., in calcareous material) is one 
of the conditions accused as the first cause of the establish- 
ment of a hereditary tendency. Thus, a deficiency of lime 
has been held to result in late or bad teeth. This is perfectly 
correct, theoretically; but, as a result of years of experiment- 
ing upon the human being, I have come to the conclusion 
that we are not in a position to directly affect the teeth by any 
remedy we may give. Any one of the so-called proximate 
principles of the tooth may be given indefinitely to a child, 
and the effect upon the tooth is nil. We may (and it has been 
done by many) produce conditions in the lower animals which 
will affect the teeth most decidedly, but such artificial con- 
ditions can be conceived of as in relation to the human being 
only in very exceptional cases. It would be difficult to con- 
ceive of a condition, for instance, in which all earthy material 
is absent from the food, unless we would take absolute starva- 
tion into consideration. It is highly probable that a deficiency 
of earthy salts in the food extended over a great period of 
time docs affect the teeth, but hardly in the direction that is 
□nder discussion at present. There can be no doubt that 
children arc made rachitic by deficient salt-supply, but this 
deficiency rarely manifests itself in time to affect the first 
teeth ; in other words, when the food is so bad as to affect the 
teeth to the extent of preventing the small quantity of cal- 
careous matter Deeded to cause them to make their appearance 
in the mouth, the child will not survive. The effects of 
drinking-water can be taken into consideration only as regards 
the permanent teeth, since children at the breast do not receive 
enough water to produce any changes in the teeth. As far as 
tin' permanent teeth are concerned, no conclusive relation has, 
a- y i, been established. 

There is a good rule for the time of the eruption of tie' 



144 DISEASES OF THE MOUTH (XON-SURGTCAL). 



permanent teeth : they appear in the same order as the milk- 
teeth and at a number of years corresponding to the months 
of the milk-teeth, with the exception of four teeth, — the first 
molars. The Jatter teeth appear about the sixth year; they 
are the first to come through after the second molars in the 
temporary set, and are found directly behind them. Changes 
take place in the temporary teeth while this is going on ; the 
bony septa between them and the permanent teeth are being 
absorbed, their blood-supply is being cut off because of the 
obstruction of their arteries, and gradually, as the result of 
absorption, they are ready to drop out. Momentous altera- 
tions in the whole economy are ascribed to these changes by 
some authors, for which there is even less reason than for 
those attributed to the temporary teeth, and which must be 
looked upon in all cases as cerebral, — either upon the part of 
the physician or upon that of the patient. 

As there are thirty-two teeth in the permanent set, the 
above rule is one that can be accepted only in the rough, but, 
nevertheless, is one that facilitates memory very much. The 
second teeth to appear are the canines, from the seventh to the 
eighth year. These are followed by the bicuspids or pre- 
molars, about the tenth year ; then the canines, about the 
twelfth year; and finally the molars, from the twelfth to the 
twenty-fifth year. 

A table would be constructed as follows : 



First 
Molars. 


Incisors. Bicuspids. 


Canines. 


Second 
Molars. 


Third 

Molars. 


G years. 


7-8 years. 9-10 years. 


12-14 years. 


12-15 years. 


17-25 years. 



Symptomatology. — The fact that teething is a physiological 
process has given rise to a peculiar line of argument, — viz., that 
for this reason no harm can come to the subject as a result of 



DEXTITIOX. 145 

tlie appearance of the teeth. On the other hand, the violent 
adherents of teething sicknesses have overlooked the equally 
well established fact that morbidity of children is greatest 
during the first year of life, and so we have developed the 
two extremes which have been mentioned before. The whole 
discussion of the symptomatology of dentition becomes a very 
difficult one because the reasoning post hoc ergo propter hoc 
lias been constantly employed, much to the detriment of our 
conclusions. As far as the physiological nature of the process 
is concerned, it is but necessary to be reminded of the daily 
observation that every act which is physiological may become 
pathological, and, as a matter of fact, has been observed as 
being pathological. So that from the stand-point of deduc- 
tion from other processes of the same nature alone we must 
admit that pathological teething, dentitio dfficilis, does exist. 
It is the province of observation to determine to what extent 
and in what direction these symptoms of a normal process 
become abnormal are developed. It is of equal importance, 
in addition, to establish the connection that exists between the 
process and the symptoms, and, if possible, to establish this 
connection by facts. Teething, in a healthy child, produces 
very few symptoms of any kind. This is admitted on all 
hands for the incisor teeth ; it is claimed, however, that the 
molars and the canines always produce symptoms more or 
less intense in their nature. These symptoms can be grouped 
under two headings for convenience of discussion, — local and 
general. The local signs arc said to be: salivation, redness, 
pain or itching, swelling, even ulceration. 1^ we examine care- 
fully into each one of these symptoms it, may become possible 
to determine the relation it bears to teething. The history 
of the physiological flow of saliva in an infant is as follows: 
The maximum amount — i.e., the greatest quantity — of saliva 
which flows from the month is found between the third and 
fourth month of life. Before this time it is nil, and from this 



146 DISEASES OF THE MOUTH (xOX-SURGICAL). 

time it begins to diminish. Now, this physiological flow of 
saliva is ascribed to an irritation produced upon the lingual 
branch of the fifth nerve by the lower incisor teeth. As a 
result of this irritation by teeth that are still within the jaw, 
but which are supposed to be growing rapidly so as to make 
their appearance within the next three or four months, reflex 
action is set up through the glosso-pharyngeal and facial 
nerves, producing an increased activity of the salivary glands. 
All this produced by the incisor teeth, which cause so little 
irritation that the baby is put to bed at night without a tooth 
and taken up the next morning with one of its little incisors 
through ! So few symptoms present that the watchful nurse, 
the anxious mother, and, possibly, the doctor have not even 
surmised the possibility of the child's teething, although they 
have been on the lookout for three months, since the saliva- 
tion began ! Now we come to another view of the question. 
The molars are about to come through ; they have broad sur- 
faces, four points, and if any tooth can irritate the mucous 
membrane of the mouth this is the one that does it. But if 
there is any salivation, it is very little compared with that of 
the third or fourth month of life; when it does occur, it is 
always due to some inflammatory changes in the mucous mem- 
brane of the mouth. The salivation, then, cannot be due to 
teething as a result of reflex mechanism. Its cause is a dif- 
ferent one: the salivary glands are developing; any irritation 
is sufficient to set up a flow of saliva; the cortical salivary 
centres, the inhibitory centres, are badly developed at this time 
of life; and, lastly, the child has not yet learned what to do 
with this fluid which it has not been accustomed to have in its 
mouth heretofore. 

The other local symptoms depend largely upon the nature 
of the child for their development. It is certain that a great 
many children get all of their teeth without the development 
of any local signs whatsoever. The physician must be on his 



DENTITION. 147 

guard not to accept as signs of teething all the many com- 
bined movements of hands and mouth that have been put 
down in midwifery lore as characteristic for this period. The 
putting of fingers into the mouth by the child may mean very 
much or very little. It may mean that the child has learned 
to use its fingers for the gratification of its highest pleasure 
and aim in life, — sucking; it may mean that there is some 
irritation, better pruritus, about the gums, for when there is 
pain, as in .stomatitis ulcerosa, the child is very careful not to 
put its fingers into its ruouth ; finally, it may mean irritation 
very much deeper than the gums. 

The fact that children do have pains during teething cannot 
be denied, but the case of the eruption of a wisdom-tooth in 
an adult is not to be looked upon as going very far to prove 
that a child ought to have pain when it cuts a molar or an 
incisor. The wisdom-tooth in an adult is, to begin with, a 
more or less rudimentary organ, badly developed, frequently 
diseased, and in the lower jaw crowded through space not suf- 
ficiently liberal, bounded in front by the second molar tooth 
and behind by the lower jaw. Would a comparison with the 
pain produced by the permanent teeth not be a much fairer 
estimate of the number of children that suffer from teething? 
Observations in this direction would show that pain, swelling, 
redness is by no means as common as is generally supposed. 

The remote symptoms that have been ascribed to teething 
are many, and in this connection are found the many impos- 
sible and improbable combinations that have played such sad 
havoc in pediatrics. In the present state of our knowledge 
it cannot be expected that a great many of these be discussed 
Beriously, nor will it be at all satisfactory to any reasoning 
person to claim that because a certain disease occurs while a 
child is teething, this <li.-ra-e must necessarily be due t<» teeth- 
ing, 'fix; etiology of disease is by no means a closed book, 
Imt enough has been done to exclude impossible combinations. 



148 DISEASES OF THE MOUTH (nOX-SURGICAE). 

Any one claiming that an inflammation of a remote organ is 
due to teething, for example, would have to be able to make 
out a very much stronger case than would be implied in the 
mere statement of the two facts, — teething and inflammation. 
A great many of these combinations still exist, and they exist 
principally because authors deem it their duty to copy what 
has been written by others without sifting the evidence and 
without bringing their own experience to bear upon the sub- 
ject. Again, it is difficult to rid one's self of preconceived 
ideas, and one who has been taught that certain combinations 
exist will find it a great task to discover the existence of 
something beyond the two combined points. On the other 
hand, one who has not been taught these combinations or who 
has disregarded them will, possibly, be just as likely to err in 
the opposite direction, — to disregard them. For these reasons 
an impartial judgment is very difficult. 

What was said of the local symptoms may be said with 
equal propriety of the general symptoms : they depend for their 
development upon the nature of the child. Given a poorly- 
nourished, badly-developed child, or one with a distinctly 
nervous, hereditary tendency, and it will suffer very much 
more from anything than one perfectly healthy. A child of 
this description will be less able to endure pain, will suffer 
more, and will, therefore, react more decidedly than one better 
prepared by reason of good condition. 

A teething child, when it suffers at all, will be found to 
have changed its disposition for the time being. It becomes 
irritable, fretful, cross, difficult to amuse, has less appetite 
than usual, its sleep is more or less disturbed, and presents all 
the signs of what might be termed malaise in a young child. 
With this there may be a slight elevation of temperature, in- 
creased thirst, and rapidity of pulse. This condition usually 
precedes the eruption of a tooth and disappears suddenly 
either before or after the tooth has come through. The more 



DENTITION. 149 

irritable the child is, naturally, the more marked are these 
symptoms. 

The symptoms on the part of remote organs can be grouped 
under the following heading: Symptoms on the part of the 
nervous system, the digestive apparatus, the skin, the respira- 
tory apparatus, the gen i to-urinary system, and the organs of 
special sense. For the nervous system it is principally con- 
vulsive disorders, partial or complete, that are ascribed to 
teething. The physiological facts that are brought in to explain 
these convulsions are as follows : In young children the in- 
hibitory power of the brain is very much less than in adults, 
therefore any afferent impulse would be followed by a very 
much greater reaction than in the adult. This reaction is sup- 
posed to manifest itself in the form of generalization of re- 
flexes, — i.e., convulsive movements. While these facts are 
perfectly correct from a theoretical stand-point, it does not 
follow that their application is absolutely so. In the case of 
teeth the afferent impulse is carried through the fifth pair of 
nerves to the medulla, and from here it is carried as efferent 
impulse by the nerves of the face and also the spinal nerves, 
not being restrained by the normal inhibitory power. The 
force that generates the nervous impulse is supposed to be 
pressure upon the peripheral termination of the nerve in the 
mouth. In order to get a convulsion from teeth, two things 
must be taken into consideration : First, the amount of pressure 
or irritation ; secondly, the irritability of the nervous system, 
the whole or various parts of the reflex arc. It seems to me 
that the first element can be excluded, in that it alone could not 
quantitatively be held accountable for the convulsion. Such a 
statement is only justifiable as a result of comparison with 
something that is tangible, with some disease in which we are 
qualified to judge of the quantity of pain there is present. It 
is next to impossible to judgeofhow much or how little pain 
is produced by the tooth's pushing through the mucous 



150 DISEASES OF THE MOUTH (NON-SURGICAL). 

membrane; the probabilities from a theoretical stand-point 
being that this quantity is very small. The reason for this 
statement will be found in the fact that the tooth has been 
pressing upon the nerve filaments for some time, producing 
functional paralysis, if not atrophy. It is more than probable 
that the pain of teething is the result of the catarrhal stoma- 
titis that is always present, or of pressure upon neighboring 
teeth or tissues. In phlyctenular conjunctivitis or keratitis 
we have a disease in which we know that the pain and irrita- 
tion are very great, and yet no author claims that this disease 
is followed or accompanied by general convulsions. We do 
find a tonic contraction of the orbicularis palpebrarum, but 
nothing more. It seems to be stretching a point to make the 
irritation of a tooth produce general convulsions, and the 
greatest irritation of one of the most sensitive organs of the 
body to be followed only by a local disturbance. Teething 
convulsions can be produced only, then, by a too great irrita- 
bility of the nervous centres ; unfortunately, this can neither 
be proven nor disproven, so that there is nothing left but 
to take the statement of authors and to have recourse to 
observation. The authorities vary very much, and while, 
theoretically, the possibility of the production of general con- 
vulsions from teething cannot be denied, the probability of 
such a combination must be rejected. For myself, I am free 
to confess that I have never seen a case of teething spasms. 
In every case of convulsions that has come under my observa- 
tion it has been easy to detect a much more plausible cause, 
which, when removed, caused the convulsions to cease. If we 
resort to the following method of determining the cause, how- 
ever, our conclusions are not apt to be very convincing. Say 
we rub a tooth through in a patient ten months old ; patient 
being fed upon improper food, — slightly constipated; after hav- 
ing given a dose of calomel and the convulsions have stopped, it 
is not fair to ascribe the spasm to the poor, maltreated tooth. 



DENTITION. 151 

Yet this is being done daily, and the physician is not willing 
to admit that the convulsion is most likely caused by the 
absorption of some substance from the intestine, and not by 
the tooth. Even if the tooth fails to make progress and the 
wound which has been produced by the rubbing heals up, so 
that the local conditions are the same as they were before the 
doctor interfered, — and the child ought to have convulsions all 
the time, — the course of reasoning is not altered ; a child with 
convulsions, a doctor to rub, convulsions to cease, therefore the 
rubbing doctor cured the convulsions due to a tooth. For 
practical purposes it is much safer to say that teething never 
produces convulsions than to hold that convulsions, as a rule, 
are caused by teething. Even the manifestation of local con- 
vulsive movements ought to be carefully examined into before 
a positive conclusion is arrived at. It is not going too far to 
state that, as a cause for convulsions, teething ought to be 
looked upon as the last etiological factor and not as the first. 
Only after every other possible source has been examined into 
ought we to be willing to admit teething as a cause for spasms, 
since it is necessary to conceive of something, — a something 
that may exist and possibly does exist, hut a something which 
is very rare and, at the present, thoroughly unknown. 

On the part of the digestive apparatus all forms of trouble 
have been attributed to teething, from the ordinary dyspeptic 
vomiting to a general affection of the whole alimentary tract. 
The mechanism of these lesions has been principally attributed 
to the irritation that follows the swallowing of great quantities 
of saliva. Prom what has been said before, it will be seen 
that this cannot by any possibility be the true cause, for the 
flow of saliva is usually very much diminished or has entirely 
ceased by the time that teeth make their appearance. In con- 
nection with diseases of the alimentary tract the teething 
theory has been followed by the most pernicious results. It 
would not be in accordance with daily observation to say that 



152 DISEASES OF THE MOUTH (NON-SURGICAL). 

teething does not have any influence upon the bowels, but this 
is to be by no means understood as intimating that it is fre- 
quently or directly the cause. The only effect upon the bowels 
is that they participate in the general irritability of the child. 
Just as the skin may become hyperresthetic, so the bowels may 
become less tolerant, and an absolute adherence to physio- 
logical food will soon clear up the bowel complaint. In other 
words, at this time, the digestion will be interfered with to 
such a limited extent as to cause food not strictly proper, but 
well borne at other times, to produce disagreeable effects upon 
the bowels. It has been pointed out that teething diarrhoea 
has peculiar properties, so that it can be differentiated from 
other forms. I must confess that I have failed to find these. 
The stools may indicate a disturbance in any one or more 
sections of the bowel so as to be characteristic or not; the dis- 
turbance is of very short duration and always amenable to a 
strict diet. In some children constipation is supposed to be 
produced by teething; this, however, is most probably a coin- 
cidence. There is one thing that ought not to be forgotten in 
connection with the intestinal lesions produced by teething: 
the children are old enough to come to the table, they make 
known their wants, sometimes are able to satisfy themselves 
by getting what they want, and in every respect are most 
unlikely to be kept upon physiological food. There is no 
question of the fact that the mure carefully children are 
watched, the more carefully they are fed, the less liable 
are they to teething diarrhoeas. It has always been my firm 
conviction that if a child were kept upon absolutely physio- 
logical food, that child, provided it were otherwise healthy, 
would not have diarrhoea from teething. Here, as before, it 
cannot be too strongly insisted upon that the physician look 
to other causes besides teeth before he takes it for granted that 
he is dealing with teething diarrhoea. The peculiar fatalism 
of allowing a diarrhoea to go on because it is due to teething 



DENTITION. 153 

is perfectly unintelligible. The "checking the bowels" can 
do no harm, aud danger can and does arise when the catarrh 
of the intestines is allowed to continue. Many a case of 
tuberculosis can be traced to this pernicious doctrine, many in- 
valided children owe their bad health to this preconceived 
notion, and many a life could be saved if only the trouble 
were taken to institute proper feeding, which can certainly not 
be harmful; this method can be pursued even where the 
physician objects to giving medicines to stop the diarrhoea. 
In addition, the doctrine engenders carelessness, both with 
physicians and laymen, so that grave lesions are frequently 
overlooked. 

The symptoms on the part of other organs must be ascribed 
to coincidences. It would take a vivid imagination, in the 
present state of our knowledge of inflammation, to conceive 
of a production of a bronchitis by the wetting of a child's 
breast from the saliva, which is supposed to be present during 
teething. The same may be said of the presence of the gono- 
coccus in urethral or vaginal discharges, which are supposed 
to be due to teething. As for the skin, young children do 
have delicate skins, the least irritation may produce a general 
eruption. A flea-bite will cause the child's skin to be covered 
with an erythema or an urticaria; the same can be said for a 
bed-bug or any insect sting. It is logical to conceive that an 
eczema may be set up by the irritation which follows a con- 
stant outpouring of saliva over the skin; but we fail to find 
any connection between teething and the various other forms 
of .skin trouble that have been attributed to it, such as lichen, 
herpes, pemphigus, etc. The mistakes that are made in this 
direction frequently become ludicrous. It is not long ago that 
a child was brought to me with a " teething impetigo" which, 
notwithstanding the teeth had appeared and notwithstanding 
the internal use of ail sorts of remedies, would not get well. 
To the great astonishment of all concerned, a needle put into 



154 DISEASES OF THE MOUTH (NON-SURGICAL). 

one of the pustules succeeded in bringing out a small black 
body, which, under a magnifying glass, disclosed itself as an 
acarus scabiei. 

In teaching I have, for years, put down for my students 
an axiom that " teething produces teeth and nothing more." 
While theoretical conceptions cause us to deviate slightly from 
this position, it will be found that the more acute the diag- 
nostician, the more accurate and searching the examination, 
the nearer the truth this statement. 

Treatment. — It would be waste of time to discuss the various 
means and remedies that have been proposed in order to make 
teething easier. Whether we give to the child a hard or a 
soft body to put into its mouth is a matter of the utmost in- 
difference, but one thing ought to be insisted upon : nothing 
which has a bad effect upon the digestive organs should be 
given to the child to facilitate teething. The only remedy at 
our command to insure normal teething is to keep the child 
in good health. To this end, at the time of teething as well 
as at all other times, the child must receive proper food, suffi- 
cient oxygen, be kept clean, and clothed properly. Such a 
child, without hereditary tendencies or acquired disease that 
may affect the teeth, will not be disturbed to any appreciable 
extent by teething. If we find that the child becomes irrita- 
ble and cross at the time when teeth can be reasonably ex- 
pected, it will be found advantageous to redouble our attention 
as to diet. At this time also, instead of keeping the patient 
in-doors for fear of catching cold, the opposite policy will be 
found very serviceable. Send the child out into the air as 
much as possible ; nothing acts so well in a fretful child. It is 
not necessary to bundle the child up to suffocation. The dress 
of the patient should be suited to the season of the year ; no 
bandages, no flannels, no woollens are necessary in summer; 
the cooler the child can be kept the more comfortable will it 
be. In winter the child should be dressed warmly ; it is not 



DENTITION. 155 

necessary to protect any especial organ against any especial 
disease, either at the teething time or at any other. A great 
deal of discomfort could be spared children if laymen as well 
as physicians were able to shake off some of the old super- 
stitions connected with the theory of catching cold. 

If the child should have increased temperature, the luke- 
warm bath will not only control it, as a rule, but will also 
assist in removing the cause of the fever. In order to remove 
the cause effectually it will be found necessary, in some cases, 
to administer a laxative. — rhubarb or calomel, — to be followed 
up by washing out the large intestine. In other cases, where 
there seems to be no trouble from bad feeding (and this can 
be determined only by the strictest search into the history, 
including, if possible, an examination of the stool), it will be 
found that the internal administration of the bromides will 
give the patient much relief in that it seems that the fever is 
due directly to some effect upon the heat-centres. Every one 
who has examined into the subject of infant-feeding will, I 
think, admit that no positive conclusion can be arrived at 
regarding the food of any ordinarily kept child without ex- 
amining the stools. If those who are so quick at drawing 
conclusions between teething and diarrhoea would take the 
trouble to search the stools carefully, they might find reason 
to change their opinion. It is a very Common occurrence to 
have both the mother and the nurse disclaim any error of diet, 
and to find, upon examination, a piece of undigested potato, a 
bit of apple, or some other equally unphysiological body in the 
faeces. Above all, it is wise for the physician to wait a little 
while before he makes up his mind that he is dealing with a 
dentition disease, so that he may examine his case carefully 
before he comes to a conclusion which lias few chances in its 
favor. [f this conclusion should be arrived at as a dernier 
redsort, the diarrhoea must be treated as any other diarrhoea 
would be. Whatever Bovereign remedy the physician has he 



15G DISEASES OF THE MOUTH (NON-SURGICAL). 

must use, especially in hot weather. Without wishing to dis- 
parage the use of the so-called intestinal antiseptics, I am free 
to confess that, to my mind, the profession is going too far in 
giving up the use of opiates in intestinal disorders of children. 
After the cause of the diarrhoea has been removed mechani- 
cally by washing out the stomach or the intestines, there is 
left in the stomach or intestines an anatomical change which 
opium, in its action, is especially fitted to benefit, and which is 
very little, if at all, affected by antiseptics. Without going 
too far in this discussion, it is but proper to state that we are 
not warranted in giving up the results of years of experience 
for a theory not, as yet, properly proven nor thoroughly 
worked out. 

Xo one remedy has been considered so much in the light of 
a specific against the maladies of teething as lancing the gums. 
More especially is this true among English-speaking people. 
Emanating, as we will see, from a celebrated French surgeou, it 
was taken up anil diffused by the English, and in this way 
has come to us as an inheritance of more than doubtful value. 
While with us the scarification of the gums is by no means as 
commonly done to-day as formerly, yet there are very many ex- 
cellent practitioners who still resort to this remedy both as a 
matter of routine and from conviction of its utility. The 
names connected with the historical development of the sub- 
ject of lancing the gums are principally three in number, — 
Ambroise Pare, John Hunter, and Marshall Hall. The first 
named has been neglected by most writers upon the subject 
(notable exceptions being Fleischman and Finlayson, although 
the latter's description is not correct), the second is universally 
referred to, and the third seems to get more credit for his 
amount of work than is due. The first mention of gum- 
lancing is found in the editiou of 1579 of the works of Am- 
broise Pare, at the end of his book, " De la Generation*' 
(numbered variously), and in all subsequent editions and 



DENTITION. 157 

translations. The statements made are the same as to facts, 
the language is changed in some of the subsequent editions 
(French edition of 1585, Guillemeau's Latin edition of 1582), 
but only as to minor details. Pare mentions the following 
remedies : " Rubbing the gums with oil of sweet almonds, fresh 
butter, honey, and sugar, or mucilage, from the seeds of 
puceron, marshmallow, quince, and on the outside a poultice 
of barley flour, milk, rose oil, and the yelks of eggs is to be 
applied : it is of advantage to rub the gums with the brains 
of a roasted or boiled hare, because experience demonstrates 
that the gums relax, and, owing to some occult properties, the 
teeth are helped in coming through; the brain of a dog is 
also good." Sometimes these and other remedies that he men- 
tions are of no avail, " because the gum is too hard, which is 
the reason that the teeth cannot pierce them, from which fol- 
lows, on account of the tension, that the children have great 
pains, from which follows fever and other complications 
mentioned above, even death. And therefore I am of the 
opinion that the surgeon should make an incision into the gum 
upon the tooth in order that the way is opened for it so that it 
can come out more easily. This is what I have done to my 
children in the presence of M. le Feure, physician-in-ordinary 
to the king, and of Madame la Princesse de la Roche-sur- 
Yon, and of Messieurs ITautin and Courtin, doctors regent of 
the faculty of medicine at Paris, and of Jacques Guillemeau, 
Burgeon-in-ordinary to the king, and sworn at Paris." He 
then states that some nurses, as is frequently done nowadays, 
scratch through the gum with their nails "in order to make 
way for the teeth that want to come through." Pare ends 
the chapter on generation by reciting the following history 
which taught him to lance gums. He was called to make a 
post-mortem upon the eight-months-old child of Monseigneur 
de Ne vers ;" having diligently searched for the cause of his 

death, nothing was found unless it might have been the hardened, 



158 DISEASES OF THE MOUTH (NON-SURGICAL). 

enlarged, and swollen gums." When the gums were cut the 
teeth were found " ready to come through," and the conclusion 
was arrived at, by himself as well as by other physicians 
present, that " the sole cause of death was that nature was 
not strong enough to pierce the gums and push the teeth 
out."' 

Notwithstanding such high authority, the operation has never 
gained a great foothold in France, and the present status of 
the question can be shown by a quotation from Barthez and 
Rilliet : " Without denying the favorable results obtained by 
other practitioners, we must say that our personal opinion is 
not favorable to this method of treatment. We have fre- 
quently practised this small operation, but we cannot recall a 
single instance in which it seemed to have any real utility. 
We will add, in order to be consistent with truth, that to us 
it has never seemed sensible." 

We must turn to England for the fidl development of the 
practice of lancing the gums, and we begin with John Hunter 
(loc. cit. p. G09), who was the first to call attention to the 
reflex irritation produced by these foreign bodies, and, logical 
as he was, to carry out his treatment to the extreme, lancing 
freely and frequently. 

To Marshall Hall (London Lancet, 1814, vol. i. p. 244) is 
usually attributed the credit of having brought the method 
into general use. While there can be no doubt of his having 
fortified the position, yet, from what is said by John Hunter, 
we are led to infer that in his day the practice was becoming 
pretty generally accepted. Marshall Hall did the operation 
because he wanted to relieve the "nervous action" by getting 
at the nerves themselves ; therefore, " it is to the base of the 
gums, not to their apex merely, that the scarification should 
be applied. The most marked ease in which I have observed 
the instant good effect of scarification was one in which all the 
teeth had pierced the gums!" The gums should be lanced once 



DENTITION. 159 

or twice daily, if necessary ; " better do this one hundred times 
unnecessarily than have one single fit from the neglect of so 
trifling an operation." From this, as a starting-point, it will 
be seen how the process of gum-lancing has entered into the 
profession as simply a routine- method of treatment, the in- 
dication for its use being about as follows : All the diseases of 
infants are due to teething; all the bad effects of teething are 
removed by cutting the gums; therefore all children ill at the 
time of teething ought to have their gums lanced. It is very 
difficult to give any adequate conception of the amount of 
gum-cutting that is still done in Great Britain. In a discus- 
sion held in the Medical Society of London, fifteen members 
took part, of whom nine were decidedly in favor of lancing, 
three were opposed, and three non-committal. Nearly all of 
those in favor, however, had receded from the extreme views 
of Marshall Hall, and had, when they spoke of the subject, 
put for themselves certain indications, as, for instance, Mr. 
Hamilton Cartwright, who, although he thinks that convul- 
sions and diarrhoea are due to teething, cuts the gum only 
when the gum is tense and glistening and the tooth about to 
come forward, and in inflammatory conditions of the gum, 
witli tumefaction (British Medical Journal, November 8, 
1884). This discussion gave rise to correspondence, in the 
same year of the journal, in which letters are printed from 
quite a number of practitioners in England, the result of 
which certainly seems to be that the operation under discus- 
sion is still used as a routine method by a very great, if not 
the greater, number of physicians in England. Certain it is 
that all the modern English books (West, Money, Semple, 
Day, Ashby and Wright) recommend lancing in a more or 
less limited way. 

Th" operation has never extended into the medical acquisi- 
tions "I' the laity in Germany. The modern authors of Ger- 
many speak of gum-lancing as useless and, possibly, harmful, 



160 DISEASES OF THE MOUTH (NON-SURGICAL). 

and the physicians do not carry gum-lancets in their pocket- 
cases. In our own country cutting of gums still has its dis- 
ciples, and especially among dentists, although it is far from 
being an uncommon practice with physicians. Jacobi (he. clt.) 
says that "the local treatment of swollen gums, which consists 
of lancing, has fortunately become less common and popular 
than it was in former times." It may be taken for granted, 
however, I think, that the greater number of physicians no 
longer resort to the lancet as routine treatment. It mav, fur- 
thermore, be stated that most of our authors advise lancing 
of the gums in exceptional cases only. One of the most re- 
cent and most enthusiastic advocates of the operation is Starr 
("Diseases of the Digestive Organs," p. 102, 1886). "If 
there be fever, nervous irritation, sleeplessness, vomiting, ov 
diarrhoea during the progress of, and dependent upon, dentition, 
I invariably lance the gum, — provided the position of the 
tooth can be established by the touch, — making the incision 
superficial or deep according to the distance of the tooth from 
the surface." This quotation presents the status of the 
question, as far as some practitioners are concerned, in a com* 
plete way. If certain things are present which, it is taken 
for granted, depend upon teething, then the gums must be 
lanced, — a position almost as broad as that of Marshall Hall, 
who, however, had no ifs, and who was willing to say that 
these certain things were always dependent upon dentition. 
This position, however, is the exceptional one among Ameri- 
can writers; in contrast with it see Doming (" Keating's 
Cyclopaedia"), who says that the good done by the operation 
in every instance, most likely, " was a pure coincidence or the 
result of the hemorrhage (a blood-letting) or of imagination 
on the part of those interested." 

For the operation an instrumentarium quite formidable in 
size has been recommended, — a roughened coin, the lancet, the 
scalpel, and various instruments especially devised for the 



DENTITION. 161 

purpose. It will not be saying too much that, when the gums 
are to be cut, they should be operated upon lege artis, with all 
aseptic precautions. The methods that have been employed, 
again, are many. Some prefer superficial, some deep incisions ; 
some cut at the top, others cut at the base of the tooth. The 
forms of the incisions are principally three in number, — the 
linear, the crucial, and the elliptical. To these may be added 
the elliptic incision with a dissecting off of the gum, the 
cutting across the margin of the gum, and, finally, Mar- 
shall Hall's method, which consists in cutting the tissues as 
deeply as possible. 

In the discussion of the subject the following questions can 
be asked : Does the operation do good, and how ? Does the 
operation do harm, and how? In answering the first question 
we can subdivide as follows: The effect upon symptoms; the 
effect upon the process of teething when the operation is per- 
formed. There are three classes of authors, — one which believes 
in scarification unconditionally; one which does not believe in it 
at all ; and, lastly, one which thinks it does good to allay some 
one symptom. Of the latter class, the symptom which is most 
commonly picked out as being relieved by gum-lancing is a 
convulsive seizure. It is claimed that gum-lancing cures con- 
vulsions. While we are not prepared to admit that convul- 
sions are produced by teething, upon theoretical grounds we 
have been forced to admit that such a connection might be a 
possibility. How, then, can a convulsion which, upon theo- 
retical grounds only, is produced by teething be relieved by 
gam-lancing? A relief given to the centres cannot be ex- 
cluded, provided the hemorrhage be sufficiently great. The 
same can be s;tid for the local process with the same proviso. 
Blood-letting does relieve arterial pressure; convulsions pro- 
duced by brain hyperemia can be relieved by one or two 
leeches behind the ear. Indeed, the older physicians were in 
the habit of differentiating between convulsions due to menin- 



162 DISEASES OF THE MOUTH (xOX-SURGICAL). 

gitis and convulsions due to other causes by means of blood- 
letting. If the convulsions ceased, it was a bad omen ; if they 
continued, the child might recover. Again, blood-letting 
empties ptomaines from the general circulation ; if the con- 
vulsions are toxic, why should it not cure if the poison in 
the blood is reduced in quantity or taken out altogether? But 
no one would think of choosing the mouth as the place for a 
sanguinary depletion ; so that this is not the reason ascribed 
for the beneficial effects of our operation. Locally the scari- 
fication does nothing except let blood. The idea that tension 
within the sac is relieved is a purely imaginative one. There 
is no tension within the sac, and, as has been shown, there is 
more than enough room for the tooth ; so that under normal 
circumstances pressure within the sac or upon its bony sur- 
roundings, in all directions, becomes an anatomical impossi- 
bility. Under abnormal conditions lancing of the gums has 
no effect upon the condition within the tooth-sac. 

In more or less general terms it has been stated that irri- 
tation of the nerves is produced by the tooth. 

The mucous membrane above the tooth has its nerves atro- 
phied as the result of constant pressure ; in other directions 
no nerves are pressed upon ; how, then, can gum-lancing relieve 
a thing which does not exist ? But most excellent observers 
state that convulsions are relieved by gum-lancing; observers 
whose word cannot be doubted. What has happened in these 
cases? Either the hemorrhage has been sufficient, or the rea- 
soning has been of the nature first post hoc ergo propter hoc, or 
the convulsions would have stopped without any interference. 
As a matter of fact, gum-lancing neither prevents nor causes 
convulsions due to teething in all instances (see an excellent 
paper by Cairns, Edinburgh Medical Journal, 1869); in other 
words, when the conditions are not propitious the remedy has 
no effect. It is extremely easy to delude one's self concerning 
the effiracy of a remedy, especially when one is prejudiced in 



DENTITION. 163 

its favor. Convulsions in young children are a very uncertain 
quantity; depending, as they do, more upon central or systemic 
than upon local causes, they are apt to begin or cease upon 
very slight provocations. "Who has not seen a convulsion 
cease as quickly as it came? It is within the experience of 
every one to have noticed the application of most simple means 
apparently cure convulsions. On the other hand, convulsions 
will be met with that cease only after extreme measures have 
been used, or, depending upon the cause, do not cease at all. 
It is safe to say that a great many convulsions cease after gum- 
lancing that would have ceased without any interference what- 
soever. But the advocates of the lancet are not satisfied with 
this; "the operation worked like a charm," "the effects were 
miraculous," and a great many more expressions of like nature 
are to be found in their writings. A great many forget to state 
that some remedy had been given before the gum was lanced, 
which had possibly removed the cause of the convulsion. A 
great many are so preoccupied with the good results that must 
follow that their impressions are obscured, and what would be 
a sudden stoppage of the convulsions would to others be the 
natural course, — a gradual lessening until complete cessation 
has taken place. Iu my whole experience I have lanced the 
gums once; then at the earnest solicitation of a consultant. 
The result was nil, and in all other cases that I have seen in 
the practice of other practitioners the result was the same. 
Convulsions that can be cured by gum-lancing can be cured 
by the most simple means, — a lukewarm bath, a mild laxative, 
a full dose of bromide of potassium; but the principal factor 
mu.-t not be lost sightof, — viz., that they will get well of them- 
selves if the physician will be wise enough to remove the 
cause, which, as has been stated before, must be looked for 
everywhere else than in the teeth. If he wish to <lo blood- 
letting, let him get a few leeches or the artificial leech, but let 
him not ascribe the benefits of a hemorrhage to gum-lancing. 



164 DISEASES OF THE MOUTH (SOX-SURGICAL). 

In this, it is not proposed to recommend blood-letting; this 
subject is foreign to the one under discussion. 

As far as the effect upon a diarrhoea is concerned, it would 
be impossible to trace any connection between the gum-lancet 
and increased peristalsis. Here the relief that is given can be 
explained purely upon false reasoning. We would defy any 
practitioner to successfully treat an attack of cholera infantum 
or catarrh of the small intestine by neglecting the laws of diet 
and reiving upon gum-lancing alone. In reading through the 
accounts given in relieving diarrhoea by scarification, it is 
always a little gray powder, a small dose of calomel, possibly 
bismuth, careful diet, plus the lancet. We never find the lancet 
used alone as the great specific; so that all deductions drawn 
in this way must be fallacious from a scientific stand-point. 
When the physician lances the gums, he immediately gives 
directions as to the other treatment; the child is now for the 
first time treated as being ill, by its surroundings, and the 
change of diet, the additional care, and the medicines produce 
the effects that are ascribed to the lancet. As long as a child is 
simply teething it is good to keep the bowels open, say the old 
women ; the more you keep the bowels open the better; there- 
fore the diarrhoea is salutary. Very few people take their 
children to the physician with diarrhoea, if the diarrhoea hap- 
pen to occur about the time teeth ought to appear. It is only 
after they see that the child is suffering in appearance and gen- 
eral health that they find it necessary to consult the physician, 
— frequently too late for him to do anything; but after lie has 
lanced the gums they go away perfectly contented, although the 
child does not improve, and, possibly, may lose its life. If the 
physician, on the other hand, gives the proper directions, with or 
without the lancet, the child is apt to recover. Certainly, in my 
own experience, with others, the lancet has never stopped a diar- 
rhoea, and, I am equally certain that, with the proper remedial 
agents, without the lancet, failure has been comparatively rare. 



DENTITION. ] 65 

That the operation makes teething easier or more rapid is a 
point that lias been frequently urged. That teething is not 
facilitated is shown by all those statements that are made in 
regard to the number of times it is necessary to scarify. It is 
a very difficult matter to state which tooth is coming through, 
and more difficult to estimate the time when it will come 
through. More than once have I seen the wrong tooth lanced, 
and frequently teeth lanced that did not come through for 
months afterward.-. How the eruption of teeth is made more 
rapid by scarification is difficult to conceive. The movement 
of the tooth is from below upward, or from above downward, 
as the tooth happens to be in the lower or upper jaw. If, now, 
we cut the gum we do not in any way facilitate this motion, 
for the gum does not offer any resistance when the tooth is 
ready to push through it; certainly none that the moving 
tooth does not easily overcome, and the motion itself can cer- 
tainly not be increased by the gum-lancing. We are practi- 
cally digging a hole, expecting to remove the object at its 
bottom without raising it. 

We have seen that lancing, per se, does no good. Does it 
do harm ? The operation itself may be harmful in that, first, it 
produces a wound where there should be none; and, secondly, 
by hemorrhage. In these days of antisepsis we are loath to 
make wounds when they are not necessary, and, I dare say, a 
great many cases could be found in which infection of the 
scarified gum has taken place, producing much more damage 
than would have been done by the teeth. In an article by 
Behrend (Journal/. Kinderkrankheiten, iii. 6, 1844) we find a 
case of tins sort mentioned which occurred under the eyes of 
Marshal] Hall. Behrend, who was in England at the time, 
makes a strong point of the unnecessary risk that children are 
exposed to from this cause. The cicatrix that is produced as 
the n -ult of frequent gum-lancing has been spoken of as being 
another reason why the operation should not be performed, li 



166 DISEASES OF THE MOUTH (NON-SURGICAL). 

does not seem, however, that a cicatrix produced in this wav 
should offer very much resistance to the pushing tooth. On 
account of the comparative freshness and low vitality of this 
tissue the resistance might even be looked upon as less than 
that of the normal gum, although the latter is small enough. 

The danger from hemorrhage has certainly been underesti- 
mated. Although the number of directly fatal cases is suffi- 
ciently great to warrant care in this direction, it is not only 
directly, but indirectly, that hemorrhage kills, as children will 
bear loss of blood much less than adults. In looking through 
the literature I have found ten fatal cases of hemorrhage, be- 
sides two others (Hamilton and B. W. Richardson) mentioned 
by James Finlayson (Brit. 3fed. Journal, September 19, 1874). 
Of these ten, five have been mentioned before by Finlayson, — 
they are those of Taynton, Anderson, "Whitworth, Des Forges, 
and Nicol. The new ones that are added are those of Bonney 
(Lancet, 1854), A. C. Castle (Boston lied, and Surg. Journal, 
1849), two cases of J. W. Garland (ibid., 1878), and one case 
of Yale (ibid., 1878). So that twelve cases have been recorded 
in which death was due directly to this operation. That there 
are a great many more that have not been recorded no one can 
doubt, for in all these years it is certain that more than twelve 
bleeders have been lanced, in each of which the hemorrhage 
would probably have been fatal. The greatest number of 
cases in which excessive hemorrhage does harm are not re- 
ported at all ; we refer to those that produce acute anaemia 
(Behrend, Churchill, Barthez and Rilliet, Finlayson). These 
cannot be represented in tables or by statistics, — anaemia which 
produces other changes, which affects the digestion, the whole 
metabolism of the child, which causes the child to be less re- 
sistant to external noxious agents. All this should not be 
underestimated ; and when authors speak of the harmless in- 
cision of the gums, an operation of no moment, we are will- 
ing to agree with them as to the great majority of cases, but 



DENTITION'. 167 

must insist on the direct harm that is done in a much greater 
number than is usually admitted. From our stand-point 
gum-lancing does good only as a local or general depletion, 
and as such it ought never to be used. Finally, there is 
another aspect of the question which has already been referred 
to. It is the harm that is done by preventing good. It is the 
error that is constantly inculcated. It is the making of a 
routine practice, based upon purely theoretical assumption, 
which is in the way of careful diagnosis and individual devel- 
opment. A man who has settled himself to the belief that 
teething produces all the ills of childhood rarely gets beyond 
this ; if he, logically, lance gums, he can see nothing more in 
the therapy of nearly all diseases beyond this. Cairns (loc. 
di.) says that gum-lancing "tends to perpetuate a custom 
which, to say the least of it, is of a doubtful character ;" 
I would add, which is useless. The conclusions that we would 
arrive at in regard to gum-lancing are as follows : 

I. It is useless, a, as far as giving relief to symptoms ; b, as 
far as facilitating or hastening teething. 

II. It is useful only as bloodletting, and ought not to be 
used as such. 

III. It is harmful, a, in producing local trouble; b, in pro- 
ducing general disturbance on account of hemorrhage ; c, in 
having established a method which is too general to do specific 
good, and too specific for universal use. 

IV. It is to be used only as a surgical procedure to give 
relief to surgical accidents. 



168 DISEASES OF THE MOUTH (NON-SURGICAL). 



IX. 

THE TONGUE AND THE MOUTH IN DISEASE OF 
REMOTE PARTS. 

The mouth can be so easily examined that it affords certain 
guides, more or less universally accepted, to diagnosis. The 
older physicians were very careful about the examination of 
the mouth, especially the tongue; but at present, the diagnostic 
value of certain changes is largely disputed. While it would 
be difficult, in individual cases, to base a diagnosis upon the 
appearance of the mouth, yet there are to be found combina- 
tions of appearances which leave little or no doubt as to the 
disease which produces them. We are disposed to smile in- 
credulously at some of the descriptions found in the works of 
fifty years ago, yet the methods of exact diagnosis have multi- 
plied so rapidly, and purely clinical evidences are so often 
neglected, that it is questionable whether we have a right to do 
this in all instances. Certain it is that the older physicians, 
with their limited means, made diagnoses that were very 
wonderful ; and equally certain is it that we, in our generation, 
with all our physico- and chemico-medical means, overlook very 
important conditions. Indeed, it might be said of us that, ou 
account of all these diversions, purely objective examination 
is on the decline; whether a forward or retrograde movement 
it is not our purpose to discuss, but where the older physician 
would examine the tongue in a case of typhoid fever, the 
modern examines for the bacilli in the dejections. We have 
gone through the periods of pure clinical medicine, the medi- 
cine of pathological anatomy, and are now in the throes of 
etiological medicine. Every time we go through one of these 
periods, each one making a decided advance, a little is dropped 
of that which has been common knowledge, principally because 



TONGUE AND MOUTH IN DISEASE OF REMOTE PARTS. 169 

this common knowledge cannot be made to agree with the 
theoretical views held at the time. Each new method of ex- 
amination supersedes some old one, possibly not covering all 
the ground of the older one, but, nevertheless, that knowledge 
gained by the older one, and not gained by the newer, is lost 
sight of. 

One of the things that has been treated of in a step-motherly 
way is the examination of the mouth. It is true that no 
patient considers himself thoroughly examined until he has 
" stuck out his tongue" at the doctor ; but usually the examina- 
tion is performed in a perfunctory manner, and the physician 
gains very little knowledge. On the other hand, there is that 
class of physicians which makes the examination of the tongue 
the principal basis for diagnosis, and in intestinal troubles this 
and an examination of the stools seem to be sufficient to give 
a clear insight into the case. It seems hardly necessary to 
state that the truth lies in the middle; that in some cases the 
tongue is of great clinical importance, and that in a great many 
others its examination for diagnostic purposes is without value. 
It goes without saying that no case is completely examined 
unless the mouth has been looked into, and yet, in a great many 
cases, nothing is gained by this examination. 

In infants the tongue can only be examined by looking into 
the mouth, and the same rules that have been put down else- 
where hold good for this examination. The appearance of a 
normal infant's tongue has also been described in a previous 
chapter, s<> that at present we are engaged upon a discussion of 
the tongue in disease. The tongue is affected as the result of 
local or general conditions. The changes that take plaee are 
in the direction of size, shape, color, and coating or fur. As 
the tongue is a muscular organ, endowed with both nerves of 
Bpecial sense and nerves of motion and sensation, we may have 
changes which affect either one or all of these structures, pro- 
ducing paresis or paralysis, loss of taste or sensation. Loss 



170 DISEASES OF THE MOUTH (NON-SURGICAL.). 

of motion is easily diagnosticated in children; not so with loss 
of taste or sensation ; in infants the latter would be almost im- 
possible, in older children not so difficult. 

The tongue changes its size and shape principally as the 
result of the action of local causes. It becomes too large iu 
glossitis; it is somewhat swollen in those forms of stomatitis 
(catarrhalis, ulcerosa) in which its mucous membrane becomes 
infected, and this infection is carried into the body of the 
tongue. Glossitis is an extremely rare affection in children, 
due, possibly, to the absence of causes acting principally during 
adult life. Congenital largeness of the tongue is not rare ; 
this is usually associated with one or the other form of idiocy, 
and the open mouth, with the large protruding tongue, the 
saliva running out of the mouth, is sometimes sufficiently 
characteristic to lead in the right diagnostic direction. Ab- 
normally small tongues are usually the result of malformation, 
and are very rare. 

The size of the tongue usually affects its shape ; it is an 
innate tendency to keep the tongue within the mouth, and it is 
only under abnormal conditions that it is found protruding for 
any great length of time. Being confined, the teeth leave 
their impression upon the tongue's border, and, furthermore, 
as long as the tongue can be retained within the mouth it is 
usually much swollen in its vertical diameter. These con- 
ditions are somewhat different in children, but it is not un- 
common to find the marks of the teeth upon the sides of the 
tongue. 

The blood affects the color of the tongue, as a whole, more 
than any other cause. When the blood cannot be returned to 
the general circulation from the tongue, this organ becomes 
cyanotic, of a slight but decidedly bluish tint, or even purple. 
Constant and persistent coughing (pertussis) produces this 
effect, and the color of the tongue is sometimes of great 
value in establishing this diagnosis. In measles this change 



TOXGUE AXD MOUTH IN DISEASE OF REMOTE PARTS. 171 

lias already been referred to before, although it seems to have 
been overlooked by other authors. Monti (Jahrbuch f. Kin- 
derheilkunde, X. F., vi. p. 27) says, " The tongue does not 
participate in the diseased process of measles." Whether this 
slight cyanosis is due to the cough that always accompanies 
measles, or whether it is due to some change within the tongue 
itself, I am not prepared to state.* It is present in all the cases 
of measles that have come under my observation for some 
time ; but it seems impossible to disassociate it from the act of 
coughing. So much, however, may be added, that in cases of 
bronchitis, in which the cough seems to be very much more 
violent than in many cases of measles, the bluish discoloration 
may be absent. As a symptom of general cyanosis, a blue 
tongue is of some importance. Reference need only be made 
to the diagnosis of skin discolorations in the colored race, and 
this statement becomes very apparent when the statement is 
made that I know of no way by which the diagnosis of 
cyanosis can be so easily made in a full-blooded negro child 
than by examining its mucous membrane. Even in white 
children the cyanosis of heart trouble or pulmonary affection, 
especially the chronic forms, is seen to great advantage in the 
mouth. 

The absence of color, or paleness, is caused by all those con- 
ditions which produce anaemia. As a result of hemorrhage, 
the tongue may suddenly become comparatively colorless. In 
I Iodgk iii's disease, leucocythsemia, chronic anaemia, the cachexia 
of malaria, the tongue is markedly pale. In all wasting dis- 
eases of children the tongue seems smaller but decidedly 
changed in color. It is, however, the chronic forms of disease 
especially that produce this change in the color of the tongue 
OS a whole; acute processes either do not produce it or it is 

I; seems to , after repeated observations, that the eruption of 

measles appears upon the tongue, as it does upon other parts of the 
mucous membrane of the mouth. 



172 DISEASES OF THE MOUTH (NON-SURGICAL). 

masked by the coloring given to the mucous membrane. It 
is very difficult at times to get an accurate idea of the color 
of the tongue-substance; this, naturally, being more or less 
changed by conditions of the mucous membrane. That part 
of the tongue resting upon the floor of the mouth is, mani- 
festly, more available for this purpose than the dorsum; in 
very young children it is difficult to get at, and in older ones, 
where there is inflammation in the oral cavity, the filling of 
the blood-vessels masks the color of the tongue. 

The furring of the tongue is that portion of our subject 
that has been most studied. The fur upon the tongue is, 
when examined microscopically, seen to be made up of epi- 
thelial cells, molecular detritus, and organisms of various 
kinds, held together by mucus. The organisms are those 
usually found in the mouth; sometimes we find pathogenic 
organisms, most frequently the pneumococcus and the pus- 
producers. Parts of the papillae are also found, depending 
largely upon the force used in scraping off the tongue. With 
the exception of the pathogenic organisms, then, nothing specific 
is found in this fur, and it would be futile to attempt to speak 
of any specific coating for any given disease, on the basis of 
what goes to make up this coating. But if we go one step 
farther, it will be seen how a general process may be followed 
by the same process upon the tongue. We abstract entirely 
from those conditions, like scarlatina, the geographical disease, 
or syphilis, in which a definite local process is always followed 
by a well-specified appearance, which can be looked upon as 
characteristic, although I must confess to having seen a straw- 
berry tongue in several instances without scarlatina. Three 
things are requisite in order that the mucous membrane which 
covers the tongue shall be in its normal condition, — moisture, 
a proper nutrition for the epithelial coating, and sufficient 
motion. Anything which affects either of these three factors 
will cause some change in the covering of the tono-ue. If, in 



TONGUE AND MOUTH IN DISEASE OF REMOTE PARTS. 173 

diseased conditions, there be added those causes which produce 
a deposit of any foreign material, such as coloring matters, in 
the coating of the tongue, we have all the elements required 
for explaining the various kinds of fur. Flat epithelium, as 
one of the lowest types of tissue in the body, is very easily 
affected by any slight deviation from its normal nutrition. 
The epithelium found upon the tongue is more or less opaque, 
depending upon the distance it is removed from the cavity of 
the mouth : the lower layers of cells, the younger ones, are 
translucent; the older ones have what has been called a more 
granular structure. The greater the number of the latter the 
thicker the fur; the greater the number of the former the 
thinner. When anything occurs to hasten the change from 
young to old, so that there are a great many more old, opaque 
cells than normal, the tongue will be furred. When, on the 
other hand, anything occurs to prevent this change or to 
materially retard the formation of epithelium, the tongue will 
be without fur and will seem red. The effect of moisture is 
in two directions : first, upon the appearance of the cells, and, 
secondly, upon their removal. When there is too much 
moisture in the mouth, the cells are short-lived and easily 
become converted from young to old, so that there is a furred 
tongue. When there is too little moisture, the cells remain 
too long upon the dorsum of the tongue, and therefore the 
tongue will be furred. An example of the former condition 
is found in the furred tongue of salivation, of the latter in 
mouth-breathers. In long-continued fevers, in which the 
absence of moisture is the predominating cause, we have a 
peculiar condition of dry white or yellow fur, quite thick and 
adherent. When this is removed, in the course of the disease, 
there ia left a glistening, dry tongue, without very much fur, — 
the latter condition due, bowever, to a lack of nutrition, so 
that the lower layers of epithelial cells are not supplied in 
adequate numbers. 



174 DISEASES OF THE MOUTH (NON-SURGICAL). 

When there is not sufficient movement of the tongue there 
results a fur, because fewer of the old cells are removed than 
would be under normal circumstances. In paralytics we con- 
stantly see a furred tongue; in any condition in which sensa- 
tion is obtunded — high fevers, soporose or comatose states — the 
same will be observed. These three factors, combined with 
the rest, produce the dry, coated tongue of typhoid conditions, 
which finally result in cracks of the whole mucous membrane, 
giving rise to small hemorrhages, which give to the tongue a 
brown or reddish-brown color. 

The supply of nutrition to the eoithelial cells is of impor- 
tance, in that the cells that grow old have to be replaced by 
young ones. When this cannot be done, no fur is produced, 
but the tongue has a red appearance ; and if the coating be 
examined under the microscope, few adult cells are found. 
We find this condition, especially, in long-continued disturb- 
ances of general nutrition, in adults in cancer, in children in 
pantatrophia or long-continued chronic intestinal catarrh. A 
supply of too much nutritive material, overfilling of the 
lymph-spaces from too abundant blood-supply, acts very much 
like too much moisture. The cells are hastened in their course 
of life, too many older ones are produced, and there results 
furring. The place of deposit of this fur depends very much 
upon the size and shape of the tongue ; where the tongue does 
not come in contact with any other part of the mouth it will 
be thick, at the edge it will be rubbed off, leaving a red out- 
line. This is the character of cyanotic tongues, especially 
pertussis. In fevers the amount of nutritive material supplied 
plays a very important role; but we can only repeat what we have 
stated before, that there is no necessity for the production of 
the classical typhoid tongue, with crusts and fissures, as this 
can be readily prevented by supplying the factor of moisture. 

Great stress has always been laid upon the foreign ad- 
mixtures ; especially to the coloring matters. For instance, a 



TONGUE AXD MOUTH IN DISEASE OF REMOTE PARTS. 1 75 

peculiar coating of tongue has been accepted as characteristic 
of malarial troubles, — a yellow coating at the base of the 
tongue. A yellowish tongue has always been associated with 
liver troubles, aud has been followed up by a dose of calomel. 
There are many pigments that will produce a yellow color 
besides bile-coloring matter, both from within and upon the 
tongue, and a diagnosis of bilipusness, which means nothing, 
is on a level with the practitioner who is willing to prescribe 
by looking at the tongue only. If we take into consideration 
that in that form of trouble in which we know that bilirubin 
is in the circulation — jaundice — we frequently find the tongue 
clean (Henoch), often white, and rarely yellow, we certainly 
must be careful in drawing the conclusion that because the 
tongue is yellow the liver is at fault. It is just as probable 
that some chromogenic organisms or some extraneous sub- 
stance is the cause of a yellow tongue. Every one lias seen 
patients who are never without a slight yellow fur and yet 
seem to enjoy perfect health. The most ludicrous mistakes 
occur to those who overlook the fact that articles of food and 
medicinal agents give their color to the fur; rhubarb pro- 
duces a beautiful liver tongue. Deposits of pigment in the 
mucous membrane of the tongue are of much greater diag- 
nostic value. The black pigments of melanosis, the malarial 
cachexia, or Addison's disease, do much to draw the attention 
of the physician in the right direction. 

Ulcers upon the tongue have been described in other chap- 
ters. There is one form of ulceration which, from time to 
time, is described as a new discovery and considered as a 
pathognomonic sign for whooping-cough. It is a symptom 
that has been noticed by a great many of the comparatively 
older writers; indeed, no complete description of whooping- 
cough could be written without its mention, but it is not to be 
looked upon as pathognomonic, in certain conditions, when 
a child lias a long-continued '•oiigh, there appears first a cloud i- 



176 DISEASES OF THE MOUTH (NON-SURGICAL). 

ness of the frenulum lingua?, which is followed by a loss of 
substance more or less deep. This ulcer cannot be produced 
unless the child has its two central lower incisors, and occurs 
only in violent, persistent coughs in which the tongue is forced 
out of the mouth. When the cough is very severe and the 
child has its lateral as well as its central incisors, that part of 
the tongue which, in coughing, is forced and rubbed over 
these teeth may also become ulcerated. This ulcer of the fre- 
nulum has been seen by a great many authors in coughs that 
were not pertussis, and I can add my own testimony to the 
correctness of this observation. It will be found in bronchi- 
tis; sometimes, but rarely, in pneumonia; more commonly in 
the cough associated with enlargement of the bronchial glands. 
The appearance of the tongue, as a whole, the coating, and 
the cloudiness or ulceration of the frenulum linguae are very 
valuable aids to the early diagnosis of whooping-cough. 

The mouth plays a very important role in the differential 
diagnosis of the acute exanthemata. On account of the fact 
that the eruption makes its appearance in the mouth in from 
one to two days before developing upon the skin, valuable 
knowledge can be gained by careful attention to the mucous 
membrane. Especially is this the case in the early, differen- 
tial diagnosis between measles and scarlatina. The changes 
in the tongue, in measles, have already been referred to. In 
the majority of cases of measles, at least forty-eight hours 
before any eruption is to be seen about the face, we can ob- 
serve a decided reddening of the posterior pillars of the 
fauces, and with this a small reddish, or reddish-blue, papular 
eruption upon the soft palate, hemorrhagic in hemorrhagic 
measles. This lasts a few days, disappears, and not infre- 
quently leaves pigmented spots. In scarlatina, the anterior 
pillars of* the fauces and the tonsils are first reddened, and 
this is followed, in a very short time, by the appearance of 
the eruption, in the form of a bright red erythema, upon the 



TONGUE AND MOUTH IN DISEASE OF REMOTE PARTS. 177 

centre of the soft palate. From here it extends, sometimes 
developing over the posterior part of the hard palate, some- 
times over the whole mouth; the greatest development of 
this eruption is arrived at before the rash develops upon the 
skin. Although the whole mouth may remain red, during 
the early course of the disease it is more diffuse, not so punc- 
tate and not so bright. Hand in hand with this goes the 
development of the so-called strawberry tongue. At first the 
tongue is covered with a milky fur; very soon, however, the 
papillae, especially the fungiform papilla?, become enlarged 
and very prominent, the white fur begins to disappear, first 
about the edges and then towards the centre, and we finally 
have a tongue deprived of all fur, with the filiform papilla? 
apparently gone, but the fungiform very prominent, giving 
in all the characteristic tongue of scarlatina. This may be 
absent in very mild cases, and, again, may be present in other 
conditions besides scarlatina. Both of these occurrences are 
so rare, however, that they may almost be left out of consider- 
ation. In variola the erythema begins upon the posterior 
wall of the pharynx, and upon this, in a short time, there are 
developed papules, which, in their turn, are rapidly converted 
into pustules. In variola, the whole mouth participates in 
the process, and we see pustules upon the soft palate, the 
uvula, the tonsils, the hard palate, the cheeks, and the tongue. 
All this is no! uncommonly accompanied by more or less sali- 
vation, swelling of the mucous membrane, and enlargement 
of the tongue. In varicella we never see any of the prepara- 
tory stages, but always the pustule or small ulcers which are 
left where lie-" pustules have existed. My experience has 
beeu opposed to that of Lori, who says that pustules are rarely 
developed upon the mucous membrane. I have rarely seen 
a case of varicella in which there could not be found one or 
more pustules in the mouth or in the pharynx. These 
changes, briefly described, have been of the greatest assistance 

1L' 



178 DISEASES OF THE MOUTH (NON-SURGICAL). 

to me in the early differential diagnosis of the acute exanthe* 
mata. Especially has this been the case in colored children. 
The diagnosis of scarlatina, in a full-blooded negro child, 
becomes almost impossible when the changes in the mouth 
are not taken into consideration. 

The appearance and movements of the tongue are very 
much affected by lesions of the nervous system. In paralytics 
one-half or both halves of the tongue may be affected. When 
one-half is affected, as the result of a cerebral lesion, motion 
and even nutrition become changed, the paralyzed side be- 
comes smaller, and the tongue, when in the mouth, deviates to 
the healthy side ; when protruded, to the paralyzed side. In 
children, it is especially post-diphtheritic paralysis that affects 
the tongue. Disturbances in the nerves leading to the tongue 
may also produce paralysis, but this is very rare in children. 
Labio-glosso-laryngeal paralysis is a disease of later life, and, 
therefore, does not play a very important role in the semeiology 
of the mouth. 



PAROTITIS. 179 

X. 

PAROTITIS. 

Inflammations of the parotid gland are due to the local- 
ization of some morbific agent within the gland substance, 
which is usually of a general systemic nature. We exclude 
here those forms of parotitis due to trauma, and we see any 
number of general disease-producers affecting the parotid 
gland. A great many attempts have been made at classifying 
the various forms of parotitis; all of which, however, are more 
or less unsatisfactory on account of the purely pathological 
basis which underlies them. Any classification must, of neces- 
sity, be incomplete until the specific cause or causes of inflam- 
mation of the parotid gland shall have been discovered. For 
the present we are justified in making a clinical division only, 
with the reservation that future discoveries may make a great 
many subdivisions. Indeed, from clinical observation, it is 
possible to reason out more than two kinds of parotitis; but, 
as we have only probabilities and uncertainty to deal with, it 
seems wiser to defer these hair-splittings until the subject can 
be worked out from the proper stand-point. For our present 
purpose a division into primary and secondary parotitis will 
be sufficient. By primary parotitis is meant that form of 
inflammation of the parotid which develops without the inter- 
vention of any other cause than the one producing this inflam- 
mation; by the secondary form is meant that inflammation 
following or accompanying some other disease, in which it is 
rational to suppose that the poison producing this disease also 
can-'- the parotitis. Under the first heading is found, espe- 
cially, epidemic parotitis, either in its epidemic or sporadic 
form, mumps ; and, secondly, that rare form of parotitis due to 
an extension of an inflammation from the month to the parotid 
gland, by way of Steno's duct. 



]80 DISEASES OF THE MOUTH (NON-SURGICAL.). 

XI. 

EPIDEMIC PAROTITIS (MUMPS). 

This disease was thoroughly well understood by the ancients, 
Hippocrates, Celsus, Aetius, Galen, and others, and they de- 
scribed it just as it would be described to-day, even as far as 
the complications are concerned. There is, then, no historical 
development of the subject; indeed, it might be said that very 
little new has been added since the days of Hippocrates, and 
if anything new will be added it will be in the direction of 
the etiology of the disease, concerning which we are com- 
pletely in the dark. If we are permitted to judge by analogy, 
we are forced to class mumps with the acute infectious diseases : 
it lias a period of incubation, one of invasion ; the disease runs 
its course in a self-limited way ; it is contagious, and the same 
individual is subjected to only one attack. The cause of the 
disease has not been discovered ; but, as far as we know, it is a 
poison that is not very virulent ; it may limit itself to a city, to 
a village, or even to one institution (a children's hospital, an 
orphan asylum) in a place without spreading, notwithstanding 
the fact that no precautions are ever taken to prevent its spread. 
Again, it may spread from one of these places of infection, so that 
it becomes quite general. On the other hand, sporadic cases of 
mumps are not so uncommon, and with a very slight degree of 
precaution, such as would not at all influence the spread of scar- 
latina, measles, or pertussis, these cases can be made to remain 
sporadic. The disease is found in all latitudes, and, as far as 
we can ascertain, in all countries. Some regions remain un- 
touched for years, then several successive epidemics will occur, 
nobody seeming to know whence they come, and then these 
regions may remain exempt again for years. Or, in large cities, 
sporadic cases may occur at all times, and suddenly an epidemic 
may develop. In large clinics mumps may be observed at almost 



EPIDEMIC PAROTITIS (MUMPS). 181 

any time of the year. The statistics of Hirsch and Leichten- 
stern seem to prove that the disease is most common in fall and 
in winter; this must be explained upon the same principle that 
influences the occurrence of measles, scarlatina, pertussis, 
diphtheria, etc. In fall and in winter children are more apt 
to be kept in the house than in spring and summer ; if they 
come in contact with other children it will be very directly, in 
rooms. In spring and summer they are out of doors, and the 
contact there is more or less indirect, at all events in the open 
air, and contagion is not so likely to be carried. 

Much stress has been laid upon the weather as an etiological 
factor in the production of the disease; cold, damp, rough 
weather predisposing to epidemics. Although this may be 
true, the direct relation between mumps and the weather 
has not, as yet, been discovered, and when the cause of the 
disease is isolated, it will probably be found that some other 
reason can be assigned to this apparent connection. 

It would be idle to discuss the nature of the poison any 
further; this has been done very extensively, and the con- 
clusions arrived at have differed somewhat. All that we know 
is how the invasion of a human being by this poison affects 
that human being, and that has been known since the days of 
Hippocrates. The poison is probably taken up by the mouth, 
and reaches the gland through Steno's duct, to have more 
or less effect upon the general system. This, again, is purely 
hypothetical, although we have very many poisons that act 
upon the general system which act in the same way, — the 
poison of typhoid fever, of diphtheria, measles, scarlatina, etc 
For typhus fever and diphtheria this condition has been proven; 
in mumps we have a period of incubation ; then more or less 
general symptoms; a period of invasion, when, after these, the 
loeal manifestation of the poison begins, to be followed by 
local development of the poison in remote parts. This cer- 
tainly looks as if the poison first taken into I he gland multi- 



18: 



DISEASES OF THE MOUTH (NON-SURGICAlA 



plies there; .luring its biological activity in the gland pro. 
duces a something which affects the general system to produce 
the general symptoms. Again, this poison may be deposited 
in other places and develop there as it did originally. 

Children are most commonly affected between the ages of 
three and five years (Barthez and Rilliet) ; the disease is very 
rare before this time, and almost unheard of in very old people 
Here, again, we have the general law of acute infections com- 
plied with. The disease is of very rare occurrence in infants 
although it does occur in them. The fact, however, that a 
physic.an has seen a great many cases of mumps in infants 
should always lead one to doubt his diagnosis; indeed, for a 
simple matter, there are very few diseases in which so 'many 
errors of diagnosis are made as in mumps. It is further 
claimed that males are especially predisposed to epidemic 
parotitis ; statistical proofs are too meagre to prove or disprove 
this assertion. As occupation can have nothing to do with 
predisposition in this disease, it is difficult to understand why 
one sex should be more favored than the other. As long as the 
catching-cold theory held full sway in etiolo^v the most curious 
statements were to be found in the books; indeed, very few 
have, as yet, fully emancipated themselves from the cold and 
moisture theory in specific diseases. All of these statements 
however true they may be, must await the future for credence; 
at the present they have been discarded. 

The duration of an epidemic varies very much. Sometimes 
it is months, at other times a year or more, as has been inti- 
mated before; mumps rarely dies out in large cities. The 
number of cases existing in a place at a given time cannot be 
estimated except by direct count, as mumps does not figure in 
mortality tables. It is, therefore, difficult to state positively 
that a large place is ever free from mumps. Sporadic cases 
are undoubtedly due to the same poison as the epidemic cases. 
Why these sporadic cases do not give rise to epidemics it is 



EPIDEMIC PAROTITIS (MUMPS). 183 

impossible to say. That the predisposition is removed by one 
attack can be urged for a certain number of individuals; but 
a good many individuals never get the mumps, even when 
exposed, and frequently a family, into which the disease has 
been introduced, is spared the first time, to be attacked by a 
subsequent exposure. 

The period of incubation varies very much, according to 
different observers, in different epidemics. As low as from 
three to four days to the other extreme of twenty-five days 
has been observed. Leichtenstern places the period of incuba- 
tion as lasting from seven to fourteen days; Vogel-Biedert, 
nine to twenty-five days; Rilliet and Lombard, in an epidemic 
at Geneva, as from twenty to twenty-two days. It is difficult 
to fix the period of incubation for any of the infectious dis- 
eases, and it is more than probable that this period differs in 
different individuals. It would be decidedly exceptional, 
however, if any disease could vary so much in its effects upon 
the individual as, in one instance, to take three days only to 
be followed by an effect, while in the other it would take 
twenty-nine days. It would seem most likely that we are 
dealing witli an error of observation, which would be more 
than excusable in a disease like mumps, in which it might 
become impossible to localize exactly the source of infection. 

On account of the fact that post-mortem examinations in 
mumps are so exceedingly rare, our knowledge concerning the 
pathological anatomy of the disease is very limited. Three 
views have been advanced : first, that the process is essentially 
a catarrhal oik; due to an inflammation arising in the salivary 
ducts and extending to the lining of the acini; secondly, that 
the inflammation arises and is limited in the large lymphatic 
Bpaces around the acini of the gland; and thirdly, that the 
inflammation is parenchymatous as well as interstitial. The 
second view has given rise to the term periparotitis, which 
was in vogue for a long time, but has now been discarded. 



184 DISEASES OF THE MOUTH (NON-SURGICAL). 

The only absolute evidence (Bamberger) that exists is in favor 
of the last view, but there are several considerations that must 
be taken into account before it is accepted. The histology of 
the parotid gland has been worked out since Bamberger pub- 
lished his article in Virchow's Handbuch d. Spec. Path. u. 
Therapie, 1855, and it is more than likely that, microscopi- 
cally, the pictures obtained by him would be explained differ- 
ently. Furthermore, the investigations of Heidenhain have 
placed the parotid gland in a class altogether different from 
the submaxillary and sublingual glands, in that it is different 
in its structure, its physiological activity, and its nerve-supply. 
While the fact is accepted that all the salivary glands are 
sometimes affected by mumps, yet this is exceptional, and 
the differences in all respects between them may possibly be 
the reason why they are not always affected together. The 
inflammatory process, as a rule, terminates in resolution, but 
the old dogmatic statement, "suppuration, no mumps," is not 
founded upon correct observation. On the other hand, the 
suppurative cases of mumps are so exceedingly rare that they 
are to be looked upon almost like the recoveries from tuber- 
cular meningitis. A curious fact to be noted is that the 
secretion of saliva is very little interfered with. If we would 
take the trouble to examine the saliva from the affected 
gland, we might find some changes, although the observations 
of Gerhardt and Lombard seem to contradict this. It is 
hardly possible that such extensive alterations in the gland 
tissue, even if they be but interstitial, should not be followed 
by some functional alteration; the more so is this the case 
when we know how little, in an experimental way, suffices to 
change the secretion. It is therefore more than probable that 
the saliva that has been examined is mixed saliva, the com- 
bined result of secretion from the other glands, and, as one of 
them is a mixed gland, — i.e., both serous and mucous, — even 
if both parotids were affected, a difference could not be readily 



EPIDEMIC PAROTITIS (MUMPS). 185 

detected, or that part of the gland unaffected produce sufficient 
saliva to cause the digestive changes. 

As we are dealing with an acute infectious disease, the 
symptoms vary as they do in all of this class, depending upon 
the nature of the epidemic and upon the individual attacked. 
We can put down as the normal course of the disease about 
the following: the stage of invasion lasts from twenty-four to 
seventy-two hours; the local symptoms from eight to twelve 
or thirteen days, during which time the complications set in 
which may cause an indefinite sickness; but, upon the whole, 
the length of a normal attack, uncomplicated, can be put down 
as running from ten to fourteen days. In very mild epidemics 
the prodromal stage causes so few symptoms that it is over- 
looked. In very severe epidemics we have all the symptoms 
of malaise, more or less fever, as high as 104° Fahrenheit in 
the evening, sometimes vomiting and diarrhoea, and, in irrita- 
ble children, so-called brain-symptoms; twitching, restlessness 
during sleep, talking and crying out during sleep, vomiting, 
convulsions, with contracted, dilated, or unequally-contracted 
or dilated, pupils. With (he beginning of the local symptoms 
all of these general disturbances usually disappear. The first 
local symptom complained of is usually pain in a space between 
the mastoid process and the lobe of the ear; very soon this 
painful spot increases in size until the whole region around the 
ear, frequently the ear itself, and the whole side of the head 
become affected. Movement of the masseters, as in chewing, 
increases and promotes painful attacks, and in very mild at- 
tacks this is the only pain that is complained of by the patient. 
Afl a rule, the swelling begins in the same place where the 
pain is firsl noticed, to become general after from twelve to 
thirty-six hours. Upon this swelling and upon its accurate 
observation depend the accuracy of our diagnosis. The fact 
must not be lost Bighl of that the parotid gland, as its name 
implies, lies around the ear. There is a lymphatic gland 



186 DISEASES OF THE MOUTH (NON-SURGICAL). 

that lies within or upon the parotid gland ; there are lymphatic 
glands that lie behind, and others that lie below the ear; all 
of these may swell, and many a case of mumps is nothing 
more nor less than a swelling of one of these glands. There is 
but one gland that lies around the ear, — i.e., in front, follow- 
ing the general outline of the ear, below and behind,— and 
when the swelling is localized in this general outline, we are 
dealing with one thing and one thing only, — parotitis. From 
a point between the lobule of the ear and where the mastoid 
process should be the swelling extends backward around and 
forward around, and in mild cases is limited to this general 
contour. In some cases the swelling extends upward towards 
the orbit; in most cases it extends to the temporal region. 
Downward, it may go along the neck, being limited for ana- 
tomical reasons by the clavicle. All this swelling causes a 
peculiar appearance, but the effect upon the ear is especially 
characteristic. The swelling causes the ear, as a whole, to be 
shoved away from the side of the face, but on account of the 
fact that the lobule is the most movable part of the auricle, it 
is most apparent there. Indeed, the upper part of the auricle 
seems nearer to the face than under normal conditions, due to the 
swelling, while the lobule is turned up, pointing either forward 
or backward, and rotated, as a whole, slightly upon its horizon- 
tal axis. 

Heretofore we have seen the superficial swelling only; in 
some cases the process attacks deeper parts, producing dys- 
phagia, and causing pharyngitis, laryngitis, and oedema of the 
glottis. The internal swelling, in double mumps, may become 
so great as to prevent swallowing entirely, and then we have 
the aspect of a very sick patient; or the oedema of the glottis 
may become so great as to demand operative interference; both 
conditions, however, are very rare, and much consolation may 
be derived from the consideration that the acme of the process 
is attained very quickly and is very short-lived. In some 



EPIDEMIC PAROTITIS (MUMPS). 187 

epidemics the submaxillary and sublingual glands are always 
enlarged ; in others we find special lymphatic glands swollen. 
I have observed one epidemic in which the enlargement of the 
parotid gland seemed to be a secondary consideration, in that 
the principal swelling took place in a large lymphatic gland 
lying below and slightly in front of the parotid, — a gland 
belonging, probably, to the deep cervical chain. In this 
epidemic, the peculiarities of which were observed by several 
other physicians, the swelling began in this gland, was followed 
in a short time by a decided, though comparatively slight, 
enlargement of the parotid, and then ran its course in the 
usual way. 

An examination of the patient reveals other facts. The 
lymphatic glands may be enlarged, — the axillary, the inguinal, 
and the cervical ; but not much reliance can be placed upon 
this symptom : first, because this enlargement is common to 
nearly all acute infectious diseases; secondly, because it is 
impossible, in any individual case, to state that the lymphatic 
glands are not of a normal size for that individual, or have not 
become enlarged from some other cause. It is claimed that, 
in a great many cases, the spleen also is enlarged ; in another 
place ("Malaria," Keating's "Cyclopaedia," vol. i.) I have 
pointed out the difficulties that beset this diagnosis. I have 
sometimes thought that the spleen was enlarged, but certainly 
not often enough, nor constantly enough, to have made this 
symptom of any importance in the way of helping to make 
an early diagnosis. 

The patient presents an almost comical appearance when 
the -willing has arrived at its maximum. He holds his head 
still*, usually inclined towards the affected side; if both 
parotids are swollen, the head is held like a patient having 
cervical vertebral caries. The face is swollen ; if unilateral, 
one aide presents an altogether different appearance from the 
other; if bilateral, we frequently find the circumference of 



188 DISEASES OF THE MOUTH (NON-SURGICAL). 

the face much greater than that of the head. On account of 
the swelling, the play of the facial muscles is interfered with 
and the expression of the face becomes set; even laughing or 
crying may hurt so much that the patient becomes very quiet. 
The folds of the face, if there be any, are obliterated, and the 
natural depressions no longer exist; in this way the deform- 
ity may become great. In these cases the tongue and mouth 
become coated and foul ; catarrhal or other forms of stomatitis 
may develop. The swelling itself is doughy, very painful, 
the skin covering the gland tense but anaemic; when it be- 
comes red, it is usually presumptive evidence that mixed 
infection has taken place ; in other words, that some other 
virus besides that of mumps is flourishing in the infected 
tissue. Besides the local pain, it will be found that the 
patient complains most of the difficulty in swallowing, but 
this mechanical disturbance may extend to the other organs ; 
the ears sometimes become affected ; the patient complains of 
tinnitus, shooting pains in the ears, slight deafness, and, rarely, 
middle-ear trouble may arise from a case of mumps. 

Bilateral affection is common, possibly the rule; but this 
differs with the character of the epidemic. In some epidemics 
nearly all the cases are bilateral ; in others, again, very few are 
found in which both glands become affected. As a rule, both 
glands are not attacked simultaneously; the one begins and is 
followed, in a few days, by swelling of the second. The swell- 
ing in the second gland does not attain the same degree of 
intensity as in the first, although this is subject to exceptions. 

The attempt has been made to characterize the fever-curve 
of this disease ; but variations are so very common that nothing 
typical can be recognized. The. more intense the infection the 
higher the temperature ; the maximum may be observed during 
the period of invasion, to decline gradually during from five 
to seven days, until a normal evening temperature is attained, 
and to show exacerbations with the development of any com- 



EPIDEMIC PAROTITIS (MUMPS). 189 

plication. Affection of the second gland, for instance, always 
produces a rise in temperature. Close observation will establish 
the fact that all cases of mumps are attended with more or 
less fever; the rise may be very slight, but it will be found, 
especially in the evening. I have paid especial attention to 
this point, and have never, as yet, found a single case in which, 
at some time or other, there has not been a rise in temperature. 
From a theoretical stand-point, afebrile cases of mumps should 
exist, and further observation may, probably, establish their 
existence. I have never observed any case in which the maxi- 
mum was much over 104° Fahrenheit, although some cases 
are on record in which this maximum has been exceeded. In 
some epidemics we find very low temperatures, in others we 
find few cases in which the temperature does not mount up; 
we no longer look upon the degree of fever as meaning direct 
danger to the patient, yet Debize (quoted by Leichtenstern, 
Gerhardt's Handbuchf. Kinderkr., ii. p. GG5) speaks of cases 
in which the temperature remained in the neighborhood of 
104° Fahrenheit for several days, when a typhoid condition 
developed accompanied by " prostration, apathy, somnolence, 
delirium, dry fuliginous tongue and mouth." It has not been 
my lot to see such eases, and, having seen a very great number 
of cases of mump-, I am almost inclined to suspect that there 
was .-nine other reason for this combination of symptoms than 
simple epidemic parotitis; the more so, as the author reports 
moie than one case. The pulse docs not present anything 
characteristic, usually following the course of the temperature. 
The affection, without complications, and even with most «>(' 
those that arc qo< extremely exceptional, can be looked upon 
as very trivial in nature. The fact that so little is known 
on. ••riling it- etiology shows how very rare mortality i ; as 
to its Sequela?, more will have t'> be said in the future. A- a 

rule, mi attack is terminated after the glands have undergone 
the changes described before. The whole process will last 



190 



DISEASES OF THE MOUTH (XOX-SURGICAL.). 



from one to two weeks, and, in the great majority of instances, 
there is complete restitutio ad integrum. Cases will occur in 
which the duration of the disease may be somewhat longer, 
and some epidemics have been described in which there oc- 
curred veritable relapses. 

The termination in suppuration is an extremely rare one. 
The fact that very many authors have never seen suppuration 
in mumps does not put us. in the position of being able to 
reject the evidence that is given with great precision by other 
writers. Every one admits that this complication is an ex- 
ceedingly rare one, and, from the reports that can be looked 
upon as authentic, it seems that the formation of abscesses in 
mumps occurs in particular epidemics. The author has never 
seen suppuration, and has always looked upon those who have 
seen a great number of cases as having been misled by changes 
in glands near the parotid. Indeed, in all those cases which 
he has seen in which suppurating parotitis was claimed, it has 
been possible to prove that the process was not in the parotid 
but in lymphatic glands, lying either upon or below the 
parotid gland. A case of this kind is reported by Barthez 
and Rilliet, and greater care in localization would undoubtedly 
confirm the truth of the above statement. From a review of 
the literature suppuration after parotitis epidemics must, how- 
ever, be accepted as a fact, and possibly the next epidemic that 
appears will bring us cases of this description. 

The most common complication of mumps in adults is 
orchitis or epididymitis. In children this complication is 
rarer, judging by the number of recorded cases, than suppu- 
ration. The author has seen one case, in a boy six years of 
age, that ran its course in the same way as in the adult. Other 
cases are reported by De Lens, Wolff, Demme, and Homeu. 
Why this complication should arise so commonly in adoles- 
cents and adults and not in children it is difficult to say, but 
it seems almost impossible to exclude the functional activity 



EPIDEMIC PAROTITIS (MUMPS). 191 

in the adult as being one of the predisposing causes. That 
the orchitis is clue to a localization of the mumps virus can be 
taken for granted in comparing the local process of mumps 
with that of other infectious processes. 

Other complications have been recorded : albuminuria, pa- 
ralysis, such as may follow any infectious process, and troubles 
with the ear. The latter seem of special importance, as they 
may lead to complete deafness and therefore to deaf-mutism. 

Upon the whole, the prognosis is universally a favorable 
one. Exceptionally, a patient may die from oedema of the 
glottis, burrowing of pus, or one of the general complications, 
but all this is so rare that, practically, it may be neglected. 

The treatment is what might be called a typical expectant 
one. We do not know anything about the poison, we have 
no remedies that affect the process, and the complications are 
rarely such as require interference. It is the custom to cover 
up the affected gland, with cotton and to rub some oily sub- 
stance into the skin. Both are unnecessary, but inunctions 
sometimes give relief to the patient, and. the application of 
anything externally gives comfort to the surroundings. If 
complications arise they must be treated as such. 



INDEX. 



Abscess, retro-pharyngeal, 20. 
Acarus scabiei, 154. 
Acid, boric, 31, 66. 

carbolic, 104. 

hydrochloric, 96, 97. 

nitric, 96. 

osmic, 51. 

pyroligneous, 97. 

tannic, 122. 
Acne vulgaris, 23. 
^Etius, 126, 180. 
Albrecht, 115. 
Alkalies, 52. 

Almonds, oil of sweet, 157. 
Alveolus, 131. 
Amulets, 125, 126, 127. 
Amygdalitis, 60. 
Anderson, 166. 
Angina crouposa, 100. 
Antiseptics, intestinal, 166. 
Aphtha}, 9, 34, 82, 83. 

Bednar's, 43. 
Aphthous sore throat, 19. 
AristotK 126. 
Armstrong, L29. 
A raenic, 17. 
Ashley, 169. 
Astringent, 122. 
Athrepsia, 47. 
Aviccnna, 46, 127. 



Babes, 89. 

Baginsky, 42, 49, 56, 67. 101, 104. 

Bamberger, 184. 

Barensprung, 37. 

Barlow, 83. 

Barthez, 68, 71, 73, 89, 96, 129, 136, 

158, 166, 182. 
Bath, lukewarm, 155. 
Bednar, 43, 45, 129. 
Bednar's aphthae, 43. 
Behrend, 165, 166. 
Berg, 47. 
Bergeron, 73, 75. 
Berker, 109. 
Biedert, Vogel-, 183. 
Billard, 33. 
Billroth, 35. 
Birch-Hirschfeld, 53. 
Blanchet, 47. 
Bockhardt, 42. 
Boerhaave, 46. 
Bohn, 28, 33, 34, 35, 36, 37, 41, 43, 

47, 61, 68, 71, 72, 73, 76, 82, 89, 

92, 97. 
Bdkai, 20. 
Bonney, 166. 
Borax, 66. 

Borax-nnd- honey mixture, 
Bouchut, 1 1"., 1 L6, 129. 
Bretonneau, 9, 17, 68. 



194 



IXDEX. 



Breveld, 48. 

Bromides, 155. 

Bronchitis in connection with teeth- 
ing, 153. 
its effect on the color of the 
tongue, 171. 

Buck, 21. 

Butlin, 109. 

C. 

Cairns, 162, 167. 

Calomel, 67, 155. 

Cameron, 36. 

Cancer, its effect upon the tongue, 
174. 

Cancrum oris, 83, 87, 88. 

Caries, 77. 

Cartwright, Hamilton, 159. 

Castle, A. C, 166. 

Catarrh, chronic intestinal, its effect 
upon the tongue, 174. 

Catechu, tinctura, 122. 

Cauterization, 85. 

Cautery, Pacquelin, 96. 

Celsus, 180. 

Churchill, 166. 

Clarke, W. Fairlie, 20. 

Cnyrim, 38. 

Cocaine, 42, 84. 

Condylomata lata, 107. 

Copper, 09. 

sulphate, 96. 

Cornil, 89. 

Corrosive sublimate, 49, 67, 104, 121. 

Croup, 99. 

Cyanosis, general, the color of the 
tongue as a symptom of, 71. 

Cysts, 26, 32. 

retention, 43. 



Day, 159. 
Debize, 189. 
Dentition, 124. 



Dentitio difficilis, 125. 

Des Forges, 166. 

Diarrhoea, long-continued, its effect 

on dentition, 142. 
Diphtheria, 92, 99. 

of the mouth, primary, 100, 101. 
Disease, hoof-and-mouth, 38. 
Doming, 136, 160. 
Dyspepsia, 16. 

Dysphagia as produced by parotitis, 
186. 

E. 
Eczema, 153. 

ad natem, 62. 

as caused by stomatitis catar- 
rhal, 28. 
Emplastrum hydrargyri, 122. 
Enamel germ, 130. 
Epstein, 43, 55. 
Erosions, syphilitic, 106, 107. 
Erythema, 23. 

of the mouth, 23, 24. 
Eustachius, 127. 
Evanson, 96, 97. 
Excoriations, 121. 



Fevers, long-continued, their effect 
on dentition, 142. 

Finlayson, James, 156, 166. 

Fischer, 13. 

Fischl, 44, 45. 

Fissures, syphilitic, 106, 107. 

Fleischmann, L., 125, 126, 129, 131, 
136, 140, 141, 156. 

Foerster, 97. 

Follicles, muciparous, 25. 

Food, defective, its effect on den- 
tition, 136. 

Fossanagrives, 48. 

Fournier, 118. 

Freeman, 36. 



195 



Fruhwald, 90. 

Fur on the tongue, the place of 
deposit, 174. 



Galen, 9, 46, 126, 180. 
Galvano-caustic wire, 96. 
Gangrene, 92, 93. 
Garland, J. W., 166. 
Gerhardt, 36, 73, 88, 138, 184. 
Germ, dentine, 130, 131. 
Gierke, 91, 92, 95, 97. 
Girtanner, 129. 
Glands, axillary, 187. 

cervical, 187. 

inguinal, in parotitis, 187. 

lymphatic, 27, 79,81. 

as affected by parotitis, 187. 

sublingual, as affected by paro- 
titis, 187. 

submaxillary, as affected by 
parotitis, 187. 

tuberculosis of, 21. 
Glossitis, the tongue in, 170. 
Glottis, oedema of the, as caused by 

parotitis, 186. 
Glycerin, 121. 
Gonococcus, 153. 
Grawitz, 48, 50. 
Grunfeld, 115. 
Gubler, 109. 

Gums, lancing of the, L27. 
Gustin, 100. 

H. 

Hicmatfidin, 23. 

Hall, Marshall, 156, 158, 159, 160, 

161. 
Hamilton, 166. 

Hare, brains of, 157. 
Haussman, 54. 
Hebra, 125. 



Heidenhain, 184. 
Heliotrope, decoction of, 127. 
Hemorrhage, its effect upon the 

tongue, 171. 
Henoch, 71, 73, 175. 
Heredity, its effect on dentition, 

136, 142. 
Herpes, 37, 153. 

Hippocrates, 9, 33, 46, 126, 180, 181. 
Hirsch, 73, 89, 181. 
Hirschfeld, Birch-, 53. 
Hodgkin's disease, the tongue as 

seen in, 171. 
Honey, 157. 
Hunt, 14. 

Hunter, John, 128, 156, 158. 
Hutchinson, Jonathan, 114, 115, 

116, 117, 118, 119. 
Hydrocephalus, 140. 
Hyperemia, 23. 
venous, 24. 
Hyposulphites, 66. 



Icterus neonatorum, 23. 
Idiocy, prematun; teething in con- 
nection with, 139, 140. 
Intertrigo, 62. 
Iodine, 09, 71. 
Iron, white-hot, 96. 
persa'ts of, 104. 

J- 
Jaboramli, 1 1. 
Jacobi, 14, 101, 108, 129, 186, 189, 

L60. 
Jaederholm, 1 1. 
Jorg, 68. 

K. 



Kaposi, ::7. 
Keratitis, 160. 



196 



INDEX. 



Koch, 89. 
Korownin, 10. 



Lancet, 160. 

Landerer, 15. 

Lanolin, 122. 

Laryngitis, as caused by parotitis, 

186. 
Lassar, 75. 
Lead, 69, 71. 
Leeches, 120. 

Leichtenstern, 181, 183, 189. 
Leptothrix, 122, 123. 
Lichen, 153. 

Lichenoid condition, 109. 
Lingard, 87, 90. 
Linossier, 49. 
Lip, hare-, 22. 
Listerine, 85, 120. 
Loeffler, 102. 
Lombard, 183, 184. 
Lori, 177. 
Lutschbeutel, 22. 

M. 

Magitot, 141. 

Magnesia, 47. 

Marchand, 14, 15. 

Marsh-mallow, 157. 

Maunsell, 96, 97. 

Measles, the tongue in, 23, 24, 171. 

Mercury, 69. 

bichloride [see Corrosive sub- 
limate). 
Mering, 14, 15. 
Methsemoglobin, 14, 15. 
Micrococci, 91. 
Milia, 43. 
Miller, 126. 
Millet, 47. 
Minnich, 102. 



Mischterlieh, 11. 

Moisture, its effect upon the tongue, 

173. 
Money, 159. 
Monilia Candida, 49. 
Monti, 171. 

Mouth, the, as an aid to differential 
diagnosis in tho acute exan- 
themata, 176, 177, 178. 

follicular sore, 19. 

gangrene of, 87. 

how to prevent affections of, 
during fever, 30. 

hyperamia of, 23, 24. 

in varicella, 177. 

in variola, 177. 

of an infant, 10. 

how to cleanse, 30. 
Muguet, 46. 
Mumps, 180, 189. 

suppurative, 184. 
Mundfaule, 68. 
Mundschwammehen, 46. 
Mycelium, 58. 
Mycoderma vini, 48, 49, 53. 

N. 

Nageli's fluid, No. 1, 51. 
Nationality, its effect on dentition, 

136. 
Necrosis, 76, 80, 83, 85. 

tissue, 89. 
Nicati, 115. 
Nieol, 166. 
Noma, 83, 87, 88, 89. 

O. 

Odontopathie atrophique, 114. 
Odor, fetid, 78. 
(Esophagus, thrush of, 61. 
Oidium albicans, 21, 48. 
Opiates, 156. 



IXDEX. 



197 



Orbicularis palpebrarum, 150. 
Oribasius, 126. 
Oxyhemoglobin, 15. 



Pacquelin's thermo-cautery, 98. 
Palate, cleft, 22. 
Papayotin, 104. 
Papilla, filiform, 26. 

fungiform, 26. 
Papules, syphilitic, 106, 107. 
Pare, Ambroise, 127, 156, 157. 
Parotitis, epidemic, 179, 180. 

primary, 179. 

secondary, 179. 
Parrot, 47, 53, 56, 109, 114, 118. 
Paul of .zEgina, 127. 
Pemphigus, 153. 
Pepsin, 17. 
Periparotitis, 183. 
Pharyngitis as caused by parotitis, 

186. 
Phlyctenular conjunctivitis, 150. 
Phosphorus, 69, 71. 
Pierce, 132. 
Plant, 49, 56. 
Plaques muqueuses, 107. 

syphilitic, 106. 
Plenk, Jacob, 128. 
Pneumonia, catarrhal, 92. 
Politzer, 129. 

Potassium chlorate, 14, 15, 16, 22, 
81, 42, 66, 84, 122. 
poisoning by, 15, 16. 

permanganate, 42, 66, 85, 97, 
104, 120. 
Poultices, 157. 
Process, necrobintic, 80. 
Prophylaxis, 29, 66, 88, 120, 121. 
Pruritus, 147. 
Psoriasis, 109. 
Ptyalin, 10, 11. 



Puceron, 157. 
Pyorrhoea, dental, 72. 



Quince, 15" 



Eachitis, 118 (see Pickets). 
Rajewsky, 14, 56, 102. 
Ranke, 87, 88, 89, 90, 91. 
BatanhisB, tinctura, 122. 
Reess, 49. 
Rehn, 83, 137. 
Resorcin, 67. 
Rhagades, 106, 107, 121. 
Rhazes, 127. 
Rhubarb, 47, 155. 
Richardson, B. W., 166. 
Rickets, 114. 

its effect on dentition, 141, 142. 
Ringworm, 109. 
Robin, 48. 
Rosen, 46. 

Rosenstein, Rosen von, 48, 128. 
Roux, G.,49. 



Sac, dental, 130, 131. 
Saccharomyces albicans, 49, 51, 53, 
55, 56, 58, 59, 61, 62, 64, 65, 67, 
123. 
Saliva, 78, 79, 84, 103. 

from gland affected by mumps, 
185. 

in the newly-born, 10, 11, 12. 
Salivation, 81, 84, 102, 120. 

as affected by dentition, 11 ■">. 1 16. 

in stomatitis catarrhalis, 27. 

in stomatitis ulcerosa, 78,81, 84. 
Salol,31, 66, 86. 
Sannfi, 100, 101, 103. 
Battler, •'::. 



198 



INDEX. 



Scarification of gums, 126. 129, 
156-162, 167. 
its effect on convulsions, 161. 

, its effect on diarrhoea, 164. 
Schaefer, 131. 

Schizornyeetes, pathogenic, 21. 
Schnitzer, 68. 
Sc'hrakarap, 41. 
Scorbutus. 72. 
See, Prof. G., 101. 
Seitz, 101. 
Sernple, 159. 
Sequestra, 77. 
Seux, 60. 
Sialagogues, 11. 
Silver nitrate, 31, 67, 85, 97, 104, 

121. 
Simon, 48. 

Smith, J. Lewis, 97, 136. 
Sodium, bicarbonate, 31, 66, 67. 

salicylate, 31, 120. 
Soor, 46. 
Sordes, 30. 
Starr, 136, 160. 
Steiner, 129. 
Stomacace, 68. 
Stomatitis, 17. 

aphthosa, 33. 

catarrhalis, 19, 23, 39, 56, 63 
99, 102. 

diphtheritica, 99, 100. 

erysipelatosa, 17. 

erythematous, 22, 23, 24. 

follicular, 20, 23. 

gangrenosa, 83, 87. 

leptothrichia, 122, 123. 

mercurialis, 69, 70, 71, 122, 188 

mycosa, 45, 46. 

with parotitis, 188. 

scarlatinosa, 17. 

simple, 19. 

syphilitica, 105. 



Stomatitis ulcero-membranous, 68. 

ulcerosa, 15, 17, 40, 41, 68, 122. 
Stumpf, 49. 

Synostosis, premature, 140. 
Syphilide, desquamative, of the 

tongue, 109. 
Syphilis, 108, 109. 

hereditaria tarda, 117. 

infantile, 119. 

T. 

Tannin, 122. 
Taupin, 68, 71, 73. 
Taynton, 166. 

Teeth, axe-shaped, 114, 115. 
cup-shaped, 114, 115. 
cuspidated, 114, 115. 
Hutchinson's, 117. 
notched, 114, 115. 
premature, 139. 
primitive, 139. 

the, as producers of stoma- 
titis catarrhalis, 19. 
screw-driver, 118. 
sulciformed, 114, 115. 
syphilitic, 114-117. 
Teething impetigo, 153. 

its effect upon the bowels, 151, 
152. 
Temperature in mumps, 189. 

in stomatitis catarrhalis, 27. 
Thrombi, 94. 
Thrush, 33, 45, 46. 
Thymol, 85. 
Tinctura ratanhiae, 122. 
Tongue, the, appearance of, 178. 
as affected by cancer, 174. 

by hemorrhage, 171. 
by Hodgkin's disease, 

171. 
by intestinal catarrh, 
174. 



INDEX. 



199 



Tongue, the, as affected by moist- 
ure, 173, 174. 
by movement, 172, 174, 

178. 
by pantatrophia, 174. 
coating of, 26, 169, 172, 173, 
174. 
in stomatitis catarrhalis, 
26. 
color of, 169, 170-175. 
in bronchitis, 171. 
in disease, 175. 
in general cyanosis, 175. 
in measles, 24, 170. 
in pertussis, 24, 170. 
influenced by extraneous 
substances, 175. 
cyanotic, 174. 

deposits of pigment in, 175. 
geographical, 109. 
ichthyosis of, 109. 
in coma, 174. 
in high fevers, 174. 
in glossitis, 170. 
in infancy, 169. 
in long-continued fevers, 173. 
in paralytics, 174. 

when sensation is ob- 
tunded, 174. 
in stomatitis catarrhalis, 170. 

ulcerosa, 170. 
in the newly-born, 10. 
its shape, 169, 170. 
its size, 169, 170, 171. 
lichen of, 109. 
normal mucous membrane of, 

172. 
strawberry, 172, 177. 
typical typhoid, 174. 
ulcers of, in bronchitis, 170. 



Tongue, the, ulcers of, in pertuss 
175, 176. 
in pneumonia, 176. 
Trousseau, 54, 68. 
Trypsin, 104. 
Tuberculosis, 153. 
Tylosis, 109. 



U. 



Ulcers, catarrhal, 42. 
chronic, 42. 
syphilitic, 107, 108. 



Valleix, 47, 60. 
Van Wimperse, 47. 
Venesection, 124. 
Vesalius, 127. 
Virchow, 76. 
Vogel, 129, 136. 
Vogel-Biedert, 183. 

W. 

Wagner, E., 53, 59. 
Wandering rash, 109. 
Wendt, 68. 

West, 14, 68, 92, 96, 129, 159. 
Whitworth, 166. 
Wichmann, 129. 
Wolf, 68. 
Wright, 159. 



Y. 



Yale, 106. 



Zenker, 53. 
Zinc sulphate, 31, 96. 
Zone, inliltrated, 91. 
Zweifel. 10. 



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